Provider Demographics
NPI:1922048693
Name:KEELEY, KYLE J (PT)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:J
Last Name:KEELEY
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 1:4005 LAMAR AVENUE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75462-5212
Mailing Address - Country:US
Mailing Address - Phone:903-785-3861
Mailing Address - Fax:903-739-8768
Practice Address - Street 1:2206-B WEST MAIN
Practice Address - Street 2:HWY 82
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426
Practice Address - Country:US
Practice Address - Phone:903-427-1545
Practice Address - Fax:903-427-0078
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1040384225100000X, 2251S0007X, 2251X0800X
OK2640225100000X
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
TX058545701Medicaid
TX80812TOtherBCBS PROVIDER NUMBER
120502OtherSUPERIOR PROVIDER NUMBER
OK100675670BMedicaid
5385104OtherAETNA PROVIDER NUMBER