Provider Demographics
NPI:1114272093
Name:KELLY, DERK (PT,DPT)
Entity Type:Individual
Prefix:
First Name:DERK
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6004 W WELLS ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3244
Mailing Address - Country:US
Mailing Address - Phone:804-349-5941
Mailing Address - Fax:
Practice Address - Street 1:6004 W WELLS ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3244
Practice Address - Country:US
Practice Address - Phone:804-349-5941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12071-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist