Provider Demographics
NPI:1629473418
Name:PAULSON, KELLEY L (DPT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:L
Last Name:PAULSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:SPODEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1055 WESTGATE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1065
Mailing Address - Country:US
Mailing Address - Phone:651-829-4981
Mailing Address - Fax:
Practice Address - Street 1:1055 WESTGATE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1065
Practice Address - Country:US
Practice Address - Phone:651-829-4981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist