Provider Demographics
NPI:1639326887
Name:BRAY, KELLY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BRAY
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 1:1401 GETTYSBURG LNDG
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6104
Mailing Address - Country:US
Mailing Address - Phone:636-443-9910
Mailing Address - Fax:
Practice Address - Street 1:1401 GETTYSBURG LNDG
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6104
Practice Address - Country:US
Practice Address - Phone:636-443-9910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007020110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist