Provider Demographics
NPI:1568454593
Name:SHURDEN, KELLIE M (PT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:M
Last Name:SHURDEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 AKRON PENINSULA RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-7944
Mailing Address - Country:US
Mailing Address - Phone:330-752-4370
Mailing Address - Fax:866-851-8273
Practice Address - Street 1:1670 AKRON PENINSULA RD
Practice Address - Street 2:SUITE 201
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-7944
Practice Address - Country:US
Practice Address - Phone:330-752-4370
Practice Address - Fax:330-475-0504
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2384683Medicaid
OHP79822Medicare UPIN
OHSH4100303Medicare ID - Type Unspecified