Provider Demographics
NPI:1003541640
Name:QUEBEDEAUX, KELLY (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:QUEBEDEAUX
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15230 GERMANY OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-5055
Mailing Address - Country:US
Mailing Address - Phone:504-912-7807
Mailing Address - Fax:
Practice Address - Street 1:1050 S FOSTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7221
Practice Address - Country:US
Practice Address - Phone:504-912-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist