Provider Demographics
NPI:1659802791
Name:OKRUCH, KELSEY MARIE (PT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:OKRUCH
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 1:6607 CHRISSULA LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6613
Mailing Address - Country:US
Mailing Address - Phone:660-676-2582
Mailing Address - Fax:573-442-6047
Practice Address - Street 1:6607 CHRISSULA LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6613
Practice Address - Country:US
Practice Address - Phone:660-676-2582
Practice Address - Fax:573-442-6047
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010029435261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy