Provider Demographics
NPI:1033458930
Name:WISDOM, KELLY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63675 E SADDLEBROOKE BLVD
Mailing Address - Street 2:SUITE R
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85739-1297
Mailing Address - Country:US
Mailing Address - Phone:520-825-8002
Mailing Address - Fax:
Practice Address - Street 1:63675 E SADDLEBROOKE BLVD
Practice Address - Street 2:SUITE R
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85739-1297
Practice Address - Country:US
Practice Address - Phone:520-825-8002
Practice Address - Fax:520-825-8012
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist