Provider Demographics
NPI:1467137869
Name:ROGACZEWSKI, KELLIE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:ROGACZEWSKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8854 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4844
Mailing Address - Country:US
Mailing Address - Phone:208-377-5005
Mailing Address - Fax:
Practice Address - Street 1:8854 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4844
Practice Address - Country:US
Practice Address - Phone:208-377-5005
Practice Address - Fax:208-377-8484
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-8611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist