Provider Demographics
NPI:1215041025
Name:ROBERTS, KELLY LYNNE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:ROBERTS
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 1:1920 S 1ST ST
Mailing Address - Street 2:APT 502
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454
Mailing Address - Country:US
Mailing Address - Phone:612-333-6012
Mailing Address - Fax:
Practice Address - Street 1:4625 CHURCHILL ST
Practice Address - Street 2:MOTIONCARE SHOREVIEW MEDICAL CENTER SUITE 204
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126
Practice Address - Country:US
Practice Address - Phone:651-484-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02775Medicare ID - Type Unspecified