Provider Demographics
NPI:1578186763
Name:BLACK, KELLI (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BLACK
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 1:1001 OLD OLIVE WAY APT 108
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5948
Mailing Address - Country:US
Mailing Address - Phone:660-412-2013
Mailing Address - Fax:
Practice Address - Street 1:701 SUNSET HILLS DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2165
Practice Address - Country:US
Practice Address - Phone:660-385-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019042022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist