Provider Demographics
NPI:1346976032
Name:IDOM, KELSEY KATE (DPT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:KATE
Last Name:IDOM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:KATE
Other - Last Name:OSBON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1605 STUBBS AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5629
Mailing Address - Country:US
Mailing Address - Phone:318-388-8414
Mailing Address - Fax:318-388-8558
Practice Address - Street 1:1603 GOODWIN RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2907
Practice Address - Country:US
Practice Address - Phone:318-255-7550
Practice Address - Fax:318-255-7552
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11173OtherLOUISIANA BOARD OF PHYSICAL THERAPY