Provider Demographics
NPI:1467670273
Name:KELLY, KATIE BLAIR (MPT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:BLAIR
Last Name:KELLY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6362 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1506
Mailing Address - Country:US
Mailing Address - Phone:913-663-2555
Mailing Address - Fax:
Practice Address - Street 1:10777 NALL AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1231
Practice Address - Country:US
Practice Address - Phone:913-312-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005005741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist