Provider Demographics
NPI:1013766633
Name:BARRY, KELLAN ROBERT
Entity type:Individual
Prefix:
First Name:KELLAN
Middle Name:ROBERT
Last Name:BARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 BURR OAK ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-7433
Mailing Address - Country:US
Mailing Address - Phone:830-304-0504
Mailing Address - Fax:
Practice Address - Street 1:12500 JUDSON RD # 201
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-4101
Practice Address - Country:US
Practice Address - Phone:210-699-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1391899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist