Provider Demographics
NPI:1437108941
Name:CLAYBOURN, KERI RENEE (PT)
Entity Type:Individual
Prefix:MISS
First Name:KERI
Middle Name:RENEE
Last Name:CLAYBOURN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:RENEE
Other - Last Name:WILKIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:7300 E INDIANA ST
Practice Address - Street 2:SUITE 102
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2794
Practice Address - Country:US
Practice Address - Phone:812-476-0409
Practice Address - Fax:812-476-1016
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006006324225100000X
IN05009722A225100000X
KY005470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200935970Medicaid
IN000000602229OtherBLUE CROSS AND BLUE SHIELD
IN000000607010OtherBLUE CROSS AND BLUE SHIELD
IN000000607010OtherBLUE CROSS AND BLUE SHIELD
IN216070YYMedicare PIN