Provider Demographics
NPI:1174531412
Name:RUBY, KELLY (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:RUBY
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 1:137 CEDAR AVENUE
Mailing Address - Street 2:PO BOX 764
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-265-7300
Mailing Address - Fax:847-265-7301
Practice Address - Street 1:137 CEDAR AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-265-7300
Practice Address - Fax:847-265-7301
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist