Provider Demographics
NPI:1275145179
Name:MAHER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 KANIKSU LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-8742
Mailing Address - Country:US
Mailing Address - Phone:360-201-1009
Mailing Address - Fax:
Practice Address - Street 1:275 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4363
Practice Address - Country:US
Practice Address - Phone:509-522-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61088530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist