Provider Demographics
NPI:1093838450
Name:KELLEY, CAROL JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 GOLDENROD ST
Mailing Address - Street 2:#14-107
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-1763
Mailing Address - Country:US
Mailing Address - Phone:661-205-5631
Mailing Address - Fax:
Practice Address - Street 1:1800 WESTWIND DR
Practice Address - Street 2:#500
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-3055
Practice Address - Country:US
Practice Address - Phone:661-322-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL-2006-466-P172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist