Provider Demographics
NPI:1174849772
Name:RICHARDS, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 CLARK ST STE D1
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-7950
Mailing Address - Country:US
Mailing Address - Phone:419-868-7378
Mailing Address - Fax:419-868-7390
Practice Address - Street 1:1058 CLARK ST
Practice Address - Street 2:D-1
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-7949
Practice Address - Country:US
Practice Address - Phone:419-868-7378
Practice Address - Fax:419-868-7390
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03520225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant