Provider Demographics
NPI:1477802999
Name:HANSEN, KELLI MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:MARIE
Other - Last Name:ORR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1420 BRIDGEPORT TER
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4850
Mailing Address - Country:US
Mailing Address - Phone:636-448-4404
Mailing Address - Fax:
Practice Address - Street 1:3955 SUMMER FOREST DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-2643
Practice Address - Country:US
Practice Address - Phone:636-448-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012023610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist