Provider Demographics
NPI:1235351586
Name:OLIN, KELLY DENISE (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
Last Name:OLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DENISE
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:23456 HAWTHORNE BLVD
Mailing Address - Street 2:200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4716
Mailing Address - Country:US
Mailing Address - Phone:310-791-4040
Mailing Address - Fax:
Practice Address - Street 1:23456 HAWTHORNE BLVD
Practice Address - Street 2:200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4716
Practice Address - Country:US
Practice Address - Phone:310-791-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 27167225100000X
CA2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports