Provider Demographics
NPI:1235378449
Name:MC CORMICK, KELLY S (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:S
Last Name:MC CORMICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1719 CLAWSON ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4702
Mailing Address - Country:US
Mailing Address - Phone:618-462-1133
Mailing Address - Fax:618-462-3736
Practice Address - Street 1:1719 CLAWSON ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4702
Practice Address - Country:US
Practice Address - Phone:618-462-1133
Practice Address - Fax:618-462-3736
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070016904OtherLICENSE NUMBER