Provider Demographics
NPI:1588602874
Name:VREDEVELD, KELLY GERRIT (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:GERRIT
Last Name:VREDEVELD
Suffix:
Gender:M
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 1:2852 N NAVAJO DR STE A
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-4966
Mailing Address - Country:US
Mailing Address - Phone:928-772-9797
Mailing Address - Fax:928-772-9340
Practice Address - Street 1:2852 N NAVAJO DR STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-4966
Practice Address - Country:US
Practice Address - Phone:928-772-9797
Practice Address - Fax:928-772-9340
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist