Provider Demographics
NPI:1164958336
Name:KIDD-THELEN, KELLIE (PTA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:KIDD-THELEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:KIDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:432 N MILL STREET
Mailing Address - Street 2:APT. 209
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080
Mailing Address - Country:US
Mailing Address - Phone:262-388-4448
Mailing Address - Fax:
Practice Address - Street 1:3613 S 13TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-7253
Practice Address - Country:US
Practice Address - Phone:920-458-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2593-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant