Provider Demographics
NPI:1689866212
Name:GAYLES, KELLY KOPP (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:KOPP
Last Name:GAYLES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:KOPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:24 E. CROSSVILLE RD.
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075
Mailing Address - Country:US
Mailing Address - Phone:678-822-0721
Mailing Address - Fax:678-822-0724
Practice Address - Street 1:24 E. CROSSVILLE RD.
Practice Address - Street 2:SUITE 150
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075
Practice Address - Country:US
Practice Address - Phone:678-822-0721
Practice Address - Fax:678-822-0724
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.016003225100000X
GAPT009644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist