Provider Demographics
NPI:1417312307
Name:FALLER, KELSEY (PTA, ATC, LAT)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:
Last Name:FALLER
Suffix:
Gender:F
Credentials:PTA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 ALEXANDRIA PIKE
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-2166
Mailing Address - Country:US
Mailing Address - Phone:859-572-1689
Mailing Address - Fax:
Practice Address - Street 1:775 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2166
Practice Address - Country:US
Practice Address - Phone:859-572-1689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA011628225200000X
OHAT.0048542255A2300X
KYAT13262255A2300X
KYA03736225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer