Provider Demographics
NPI:1811565930
Name:WALTHERS, KELSIE MAE (OTA/L)
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:MAE
Last Name:WALTHERS
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 CREEKWOOD RANCH RD
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-8047
Mailing Address - Country:US
Mailing Address - Phone:719-355-6292
Mailing Address - Fax:
Practice Address - Street 1:3401 AMADOR DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-2227
Practice Address - Country:US
Practice Address - Phone:682-204-0853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216827224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant