Provider Demographics
NPI:1578850970
Name:KOLSTAD, KELSEY LARSON (PT, MPT, OCS, ATC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LARSON
Last Name:KOLSTAD
Suffix:
Gender:M
Credentials:PT, MPT, OCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9300
Mailing Address - Country:US
Mailing Address - Phone:307-587-9789
Mailing Address - Fax:307-587-9787
Practice Address - Street 1:544 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9300
Practice Address - Country:US
Practice Address - Phone:307-587-9789
Practice Address - Fax:307-587-9787
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist