Provider Demographics
NPI:1669955480
Name:HUANG, KERRY L (PTA)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:L
Last Name:HUANG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:L
Other - Last Name:BANCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:309 POCO ST
Mailing Address - Street 2:
Mailing Address - City:BANGS
Mailing Address - State:TX
Mailing Address - Zip Code:76823-3462
Mailing Address - Country:US
Mailing Address - Phone:254-931-4826
Mailing Address - Fax:
Practice Address - Street 1:118 S PARK DR STE D
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5957
Practice Address - Country:US
Practice Address - Phone:254-931-4826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2069548225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant