Provider Demographics
NPI:1730207010
Name:CHARLES, KELLEY (PTA)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 KENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3528
Mailing Address - Country:US
Mailing Address - Phone:513-423-9669
Mailing Address - Fax:
Practice Address - Street 1:8650 GOVERNORS HILL DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-1372
Practice Address - Country:US
Practice Address - Phone:513-791-5766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5520225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant