Active NPI
Kelly Jean Detherage, PTA
- Physical Therapy Assistant
- Weatherford, TX
National Provider Identifier
1245543966
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 2076950
- Practice address
- 1201 Holland Lake Drive
Weatherford, TX 76086 - Phone
- (817) 613-9699
- Fax
- (817) 594-9786
- NPI assigned
- Jul 22, 2010
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 2076950 | TX | Primary |
Addresses
Primary practice location
1201 Holland Lake Drive
Weatherford, TX 76086
Mailing address
4560 SE International Way
Ste. 100
Milwaukie, OR 97222
Phone (971) 206-5200
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2076950 | TX | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1279756800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1279756800000",
"number": "1245543966",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4560 SE INTERNATIONAL WAY",
"address_2": "STE. 100",
"city": "MILWAUKIE",
"state": "OR",
"postal_code": "97222",
"telephone_number": "971-206-5200",
"fax_number": "971-206-5203"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1201 HOLLAND LAKE DRIVE",
"city": "WEATHERFORD",
"state": "TX",
"postal_code": "76086",
"telephone_number": "817-613-9699",
"fax_number": "817-594-9786"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DETHERAGE",
"first_name": "KELLY",
"middle_name": "JEAN",
"credential": "PTA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2010-07-22",
"last_updated": "2010-07-22",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "TX",
"license": "2076950",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Weatherford, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.