Provider Demographics
NPI:1053742221
Name:KELM, DUSTIN DWAIN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:DWAIN
Last Name:KELM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 184
Mailing Address - Street 2:
Mailing Address - City:LORENA
Mailing Address - State:TX
Mailing Address - Zip Code:76655-0184
Mailing Address - Country:US
Mailing Address - Phone:254-723-5058
Mailing Address - Fax:254-857-2007
Practice Address - Street 1:5400 LAUREL DR.
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-399-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1237757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist