Provider Demographics
NPI:1659984813
Name:SURRATT, KELLY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SURRATT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CORPORATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7918
Mailing Address - Country:US
Mailing Address - Phone:949-759-1840
Mailing Address - Fax:
Practice Address - Street 1:15 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7918
Practice Address - Country:US
Practice Address - Phone:949-759-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298831225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist