Provider Demographics
NPI:1871182733
Name:KALLIE, CAMRI MONIQUE
Entity Type:Individual
Prefix:
First Name:CAMRI
Middle Name:MONIQUE
Last Name:KALLIE
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 1:19610 FM 362 RD APT 2002
Mailing Address - Street 2:
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-5058
Mailing Address - Country:US
Mailing Address - Phone:979-451-3458
Mailing Address - Fax:
Practice Address - Street 1:19610 FM 362 RD
Practice Address - Street 2:
Practice Address - City:WALLER
Practice Address - State:TX
Practice Address - Zip Code:77484-5005
Practice Address - Country:US
Practice Address - Phone:979-451-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT129049225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist