Provider Demographics
NPI:1447759535
Name:KISLING, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KISLING
Suffix:
Gender:F
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:DEPT 781629 PO BOX 78000
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1629
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:
Practice Address - Street 1:2011 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1787
Practice Address - Country:US
Practice Address - Phone:419-520-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA002644225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid