Provider Demographics
NPI:1508414962
Name:SMITH, KELSEY KENNEDY (PT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:KENNEDY
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ELIZABETH
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11125 SETTLERS CT
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2968
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-966-3372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011488A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic