Provider Demographics
NPI:1659383867
Name:KELSICK, STEPHANIE JANE (MSPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JANE
Last Name:KELSICK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:212 W VAN DORN ST.,
Practice Address - Street 2:STE D
Practice Address - City:POLK CITY
Practice Address - State:IA
Practice Address - Zip Code:50226-0142
Practice Address - Country:US
Practice Address - Phone:515-984-6377
Practice Address - Fax:515-984-6782
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA03561OtherPHYSICAL THERAPY LICENSE
IAI20753Medicare PIN