Provider Demographics
NPI:1982478947
Name:BLEVINS, KELLEY DIANE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:DIANE
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:DIANE
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:517 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-6003
Mailing Address - Country:US
Mailing Address - Phone:903-305-6960
Mailing Address - Fax:
Practice Address - Street 1:517 BROOKWOOD DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-6003
Practice Address - Country:US
Practice Address - Phone:903-305-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2167412225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant