Provider Demographics
NPI:1083825608
Name:STRAUS-DIEDRICK, KELLY LEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LEE
Last Name:STRAUS-DIEDRICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W387 WEILER RD
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130
Mailing Address - Country:US
Mailing Address - Phone:920-766-6456
Mailing Address - Fax:
Practice Address - Street 1:725 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985
Practice Address - Country:US
Practice Address - Phone:920-235-5100
Practice Address - Fax:980-233-7352
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist