Provider Demographics
NPI:1942456207
Name:BEAL, KELLI BRANDON (PTA)
Entity Type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:BRANDON
Last Name:BEAL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 MURRAY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-2819
Mailing Address - Country:US
Mailing Address - Phone:731-234-8081
Mailing Address - Fax:
Practice Address - Street 1:191 MURRAY LN
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-2819
Practice Address - Country:US
Practice Address - Phone:731-234-8081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3810225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant