Provider Demographics
NPI:1629045190
Name:SLOCUM, KELLY ROBYNN (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROBYNN
Last Name:SLOCUM
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 1:13 WESTERN MARYLAND PKWY
Mailing Address - Street 2:STE 104
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6474
Mailing Address - Country:US
Mailing Address - Phone:301-665-4575
Mailing Address - Fax:301-665-4576
Practice Address - Street 1:13 WESTERN MARYLAND PKWY
Practice Address - Street 2:STE 104
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6474
Practice Address - Country:US
Practice Address - Phone:301-665-4575
Practice Address - Fax:301-665-4576
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
176034YURCMedicare PIN
176034YCGXMedicare PIN