Provider Demographics
NPI:1518547207
Name:ANDERTON, KELLY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ANDERTON
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:PO BOX 380
Mailing Address - Street 2:
Mailing Address - City:CHILOQUIN
Mailing Address - State:OR
Mailing Address - Zip Code:97624-0380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9430 WILLIAMSON RIVER RD
Practice Address - Street 2:
Practice Address - City:CHILOQUIN
Practice Address - State:OR
Practice Address - Zip Code:97624
Practice Address - Country:US
Practice Address - Phone:509-435-3993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist