Provider Demographics
NPI:1508203936
Name:KELLEY, KEVIN A (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:
Practice Address - Street 1:850 43RD AVE STE 300
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8401
Practice Address - Country:US
Practice Address - Phone:309-743-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-019925225100000X
KS1104573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist