Provider Demographics
NPI:1043566425
Name:BOGOWITH, KELLY ANN (PT)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:BOGOWITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:HELLENGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5 DUNLAP COVE CT N
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2490
Mailing Address - Country:US
Mailing Address - Phone:618-799-9038
Mailing Address - Fax:
Practice Address - Street 1:815 E 5TH ST
Practice Address - Street 2:SUITE A, OUTPATIENT REHABILITATION SERVICES
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6471
Practice Address - Country:US
Practice Address - Phone:618-463-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist