Provider Demographics
NPI:1295867505
Name:EVERT, KELLY JO (PTA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JO
Last Name:EVERT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 N RESTIN RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-8583
Mailing Address - Country:US
Mailing Address - Phone:317-859-0829
Mailing Address - Fax:317-859-1244
Practice Address - Street 1:1 N RESTIN RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-8583
Practice Address - Country:US
Practice Address - Phone:317-859-0829
Practice Address - Fax:317-859-1244
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002151A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant