Provider Demographics
NPI:1528013265
Name:JOHNSTON, KELLY L (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3868 MEXICO RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303
Mailing Address - Country:US
Mailing Address - Phone:636-926-0408
Mailing Address - Fax:636-926-0295
Practice Address - Street 1:1050 OLD DES PERES RD
Practice Address - Street 2:SUITE 40
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-821-0200
Practice Address - Fax:314-821-9976
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020182402251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic