Provider Demographics
NPI:1861438152
Name:THORNTON, KELLI D (PT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:D
Last Name:THORNTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12845 FM 2154 RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-3982
Mailing Address - Country:US
Mailing Address - Phone:979-696-4800
Mailing Address - Fax:979-695-6947
Practice Address - Street 1:12845 FM 2154 RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-3982
Practice Address - Country:US
Practice Address - Phone:979-696-4800
Practice Address - Fax:979-695-6947
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1111656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1111656OtherPHYSICAL THERAPY LICENSE
TX8T1332OtherBCBS PROVIDER #
TX8T1332OtherBCBS PROVIDER #