Individual
KELLY JEAN DETHERAGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
1201 HOLLAND LAKE DRIVE, WEATHERFORD, TX 76086
(817) 613-9699
(817) 594-9786
Mailing address
4560 SE INTERNATIONAL WAY, STE. 100, MILWAUKIE, OR 97222
(971) 206-5200
(971) 206-5203
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2076950
TX
Other
Enumeration date
07/22/2010
Last updated
07/22/2010
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