Provider Demographics
NPI:1609314574
Name:PIETZMAN, KELLY (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PIETZMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2460
Mailing Address - Country:US
Mailing Address - Phone:636-485-9206
Mailing Address - Fax:
Practice Address - Street 1:148 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2823
Practice Address - Country:US
Practice Address - Phone:636-356-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017003433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist