Provider Demographics
NPI:1417919226
Name:HALLIBURTON, KELLEY LEE (ATC, PTA)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:LEE
Last Name:HALLIBURTON
Suffix:
Gender:F
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-2489
Mailing Address - Country:US
Mailing Address - Phone:217-324-4237
Mailing Address - Fax:
Practice Address - Street 1:9 RIDGE DR
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-2489
Practice Address - Country:US
Practice Address - Phone:217-324-4237
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer