Provider Demographics
NPI:1497230510
Name:MODAFF, KELLY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MODAFF
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 LUCIA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1346
Mailing Address - Country:US
Mailing Address - Phone:606-356-5320
Mailing Address - Fax:
Practice Address - Street 1:108 DIAGNOSTIC DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-6556
Practice Address - Country:US
Practice Address - Phone:502-607-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP2018118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist