Provider Demographics
NPI:1578893723
Name:ROGERS, KELLY ANN (PTA, LMT, BS)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:ANN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PTA, LMT, BS
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Mailing Address - Street 1:404 WEST BLACKHAWK DRIVE
Mailing Address - Street 2:SUITE 1LL
Mailing Address - City:BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61010
Mailing Address - Country:US
Mailing Address - Phone:815-234-5561
Mailing Address - Fax:815-234-5870
Practice Address - Street 1:404 WEST BLACKHAWK DRIVE
Practice Address - Street 2:SUITE 1LL
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010
Practice Address - Country:US
Practice Address - Phone:815-234-5561
Practice Address - Fax:815-234-5870
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL160.005347225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant