Provider Demographics
NPI:1619496536
Name:NEELY, KIRSTEN N (PT)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:N
Last Name:NEELY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:N
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2604 E. CREEK'S EDGE DR.
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401
Mailing Address - Country:US
Mailing Address - Phone:812-353-3343
Mailing Address - Fax:812-353-3346
Practice Address - Street 1:2604 E. CREEK'S EDGE DR.
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401
Practice Address - Country:US
Practice Address - Phone:812-353-3343
Practice Address - Fax:812-353-3346
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005978A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist