Provider Demographics
NPI:1639624455
Name:DEMUS, KELLY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEMUS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LESNIEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:3616 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-2159
Practice Address - Country:US
Practice Address - Phone:815-877-5932
Practice Address - Fax:815-877-6302
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.022382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist