Provider Demographics
NPI:1922838184
Name:NEWMAN, KELLY JOANN (LMT, PLT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JOANN
Last Name:NEWMAN
Suffix:
Gender:F
Credentials:LMT, PLT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JOANN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1966
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:TX
Mailing Address - Zip Code:79831-1966
Mailing Address - Country:US
Mailing Address - Phone:817-832-9578
Mailing Address - Fax:
Practice Address - Street 1:2800 W HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-4132
Practice Address - Country:US
Practice Address - Phone:817-832-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT100223225700000X
TXZP13539247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty