Provider Demographics
NPI:1083374508
Name:DEAN, KELSEY E
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:E
Last Name:DEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6966 PERNOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2118
Mailing Address - Country:US
Mailing Address - Phone:314-236-1073
Mailing Address - Fax:
Practice Address - Street 1:2 NAZARETH LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-7600
Practice Address - Country:US
Practice Address - Phone:314-236-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020036611225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM4M399W07006OtherANTHEM