Provider Demographics
NPI:1568590230
Name:MAURER, KELLY L (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MAURER
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HILANOA DR
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2533
Mailing Address - Country:US
Mailing Address - Phone:618-524-8634
Mailing Address - Fax:
Practice Address - Street 1:40 HILANOA DR
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2533
Practice Address - Country:US
Practice Address - Phone:618-524-8634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003951225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist