Provider Demographics
NPI:1619912656
Name:VILLARS, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VILLARS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 AVENUE PALAIS ROYAL
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-6402
Mailing Address - Country:US
Mailing Address - Phone:985-871-7878
Mailing Address - Fax:
Practice Address - Street 1:103 NORTHPARK BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-6119
Practice Address - Country:US
Practice Address - Phone:985-871-7878
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05264R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CG50Medicare ID - Type Unspecified