Provider Demographics
NPI:1952616765
Name:KELLEY, KATHRYN KAY (CPTA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:KAY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6536 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-9194
Mailing Address - Country:US
Mailing Address - Phone:316-776-9527
Mailing Address - Fax:
Practice Address - Street 1:116 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MULVANE
Practice Address - State:KS
Practice Address - Zip Code:67110-1718
Practice Address - Country:US
Practice Address - Phone:316-777-0977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01808225200000X
MO2001020589225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant