Provider Demographics
NPI:1336456466
Name:KELLY, WILLIAM FREDERICK (PT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:FREDERICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12266 DEPAUL DR.
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-209-7700
Mailing Address - Fax:314-209-7705
Practice Address - Street 1:12266 DEPAUL DR.
Practice Address - Street 2:SUITE 115
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-209-7700
Practice Address - Fax:314-209-7705
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001013123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist