Provider Demographics
NPI:1083646061
Name:GERL, KELLY ANN (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:GERL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:DEMELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3601 30TH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-657-0222
Mailing Address - Fax:262-657-7190
Practice Address - Street 1:3921 30TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144
Practice Address - Country:US
Practice Address - Phone:262-925-0311
Practice Address - Fax:262-652-2370
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014256225100000X
WI10212024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40449700Medicaid
WIP00169801OtherRAILROAD MEDICARE NUMBER
ILK16935Medicare ID - Type Unspecified
Q14195Medicare UPIN
ILK16934Medicare ID - Type Unspecified