Provider Demographics
NPI:1255953402
Name:KELLY, ALYSSA DAWN (LPTA)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:DAWN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 MILL RD
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-9128
Mailing Address - Country:US
Mailing Address - Phone:832-215-0757
Mailing Address - Fax:
Practice Address - Street 1:204 OAK DR S
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5628
Practice Address - Country:US
Practice Address - Phone:979-297-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2067876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant