Provider Demographics
NPI:1689269771
Name:QUALLS, DELESHA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:DELESHA
Middle Name:
Last Name:QUALLS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 HOLLY LOOP
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8368
Mailing Address - Country:US
Mailing Address - Phone:281-840-9741
Mailing Address - Fax:
Practice Address - Street 1:400 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4754
Practice Address - Country:US
Practice Address - Phone:575-623-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5376225100000X
TX1278361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist