Provider Demographics
NPI:1629188149
Name:PREDDY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PREDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 COLOGNE LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6010
Mailing Address - Country:US
Mailing Address - Phone:512-417-9751
Mailing Address - Fax:
Practice Address - Street 1:6818 AUSTIN CENTER BLVD STE 111
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3199
Practice Address - Country:US
Practice Address - Phone:512-418-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1151456OtherLICENSE #