Provider Demographics
NPI:1073627576
Name:BEAUDOIN, KELLY SUE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:BEAUDOIN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23175 COMMERCE PARK
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5806
Mailing Address - Country:US
Mailing Address - Phone:440-449-3400
Mailing Address - Fax:440-449-3402
Practice Address - Street 1:23175 COMMERCE PARK
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5806
Practice Address - Country:US
Practice Address - Phone:440-449-3400
Practice Address - Fax:440-449-3402
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10464225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2471409Medicaid
OH4118131Medicare PIN