Provider Demographics
NPI:1417339086
Name:KELLY, KYLE (PTA)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19647 THERESE LN
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1752
Mailing Address - Country:US
Mailing Address - Phone:847-909-7803
Mailing Address - Fax:
Practice Address - Street 1:12550 S RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1859
Practice Address - Country:US
Practice Address - Phone:708-597-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007018225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant