Provider Demographics
NPI:1427401157
Name:BADEAUX, KELLI (PTA)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:
Last Name:BADEAUX
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 FRANKFORD RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-6834
Mailing Address - Country:US
Mailing Address - Phone:972-232-8096
Mailing Address - Fax:972-656-3439
Practice Address - Street 1:8000 FRANKFORD RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-6834
Practice Address - Country:US
Practice Address - Phone:972-232-8096
Practice Address - Fax:972-656-3439
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2090212225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant