Provider Demographics
NPI:1518449347
Name:BRISTER, KELLEY EILEEN (PTA)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:EILEEN
Last Name:BRISTER
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 1:351 BOSQUE BEND LN
Mailing Address - Street 2:
Mailing Address - City:CHINA SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:76633-2753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:351 BOSQUE BEND LN
Practice Address - Street 2:
Practice Address - City:CHINA SPRING
Practice Address - State:TX
Practice Address - Zip Code:76633-2753
Practice Address - Country:US
Practice Address - Phone:254-749-1398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2016465225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant