Provider Demographics
NPI:1639119324
Name:HALCOMB, KENNETH SHANE (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SHANE
Last Name:HALCOMB
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 LEWIS LANE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-9331
Mailing Address - Country:US
Mailing Address - Phone:903-785-3861
Mailing Address - Fax:903-739-8768
Practice Address - Street 1:2875 LEWIS LANE
Practice Address - Street 2:SUITE B
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-9331
Practice Address - Country:US
Practice Address - Phone:903-785-3861
Practice Address - Fax:903-739-8768
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2635225100000X, 2251S0007X, 2251X0800X
TX1090686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
5197152OtherAETNA PROVIDER NUMBER
120499OtherSUPERIOR PROVIDER NUMBER
TX80813TOtherBCBS PROVIDER NUMBER