Provider Demographics
NPI:1235573346
Name:FODO, KELLY ELAINE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELAINE
Last Name:FODO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELAINE
Other - Last Name:BURGARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:27511 HOLIDAY LN STE 105
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5397
Mailing Address - Country:US
Mailing Address - Phone:419-873-3488
Mailing Address - Fax:419-873-4777
Practice Address - Street 1:27511 HOLIDAY LN STE 105
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5397
Practice Address - Country:US
Practice Address - Phone:419-873-3488
Practice Address - Fax:419-873-4777
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH014026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist