Provider Demographics
NPI:1659778595
Name:MOFFITT, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7927 SADDLEBACK PL
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-9366
Mailing Address - Country:US
Mailing Address - Phone:513-677-0807
Mailing Address - Fax:
Practice Address - Street 1:700 W PETE ROSE WAY
Practice Address - Street 2:SUITE 225
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45203-1892
Practice Address - Country:US
Practice Address - Phone:513-381-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH015111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist