Provider Demographics
NPI:1174884597
Name:KELLER, KENT (PTA)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 E. REAGAN PARKWAY, APT 215
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256
Mailing Address - Country:US
Mailing Address - Phone:330-690-9021
Mailing Address - Fax:
Practice Address - Street 1:727 E REAGAN PKWY APT 215
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1246
Practice Address - Country:US
Practice Address - Phone:330-690-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA01677225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant