Provider Demographics
NPI:1629101761
Name:DEBOOM, KELLY SHAWN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SHAWN
Last Name:DEBOOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:233 LINDELL PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-3110
Mailing Address - Country:US
Mailing Address - Phone:210-732-8408
Mailing Address - Fax:210-297-0459
Practice Address - Street 1:520 MADISON OAK DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3913
Practice Address - Country:US
Practice Address - Phone:210-297-4525
Practice Address - Fax:210-297-0459
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist