Provider Demographics
NPI:1194363507
Name:GREEN, KELBY RAE (DPT)
Entity Type:Individual
Prefix:
First Name:KELBY
Middle Name:RAE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107-7513
Mailing Address - Country:US
Mailing Address - Phone:620-960-5633
Mailing Address - Fax:
Practice Address - Street 1:625 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KS
Practice Address - Zip Code:67831-3199
Practice Address - Country:US
Practice Address - Phone:620-635-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist