Provider Demographics
NPI:1073920682
Name:MAR, KELCI DENAE (DPT)
Entity Type:Individual
Prefix:
First Name:KELCI
Middle Name:DENAE
Last Name:MAR
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 1:7809 W WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7253
Mailing Address - Country:US
Mailing Address - Phone:785-424-4846
Mailing Address - Fax:
Practice Address - Street 1:7979 W RIFLEMAN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9066
Practice Address - Country:US
Practice Address - Phone:805-571-1000
Practice Address - Fax:888-711-9067
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist