Provider Demographics
NPI:1689934416
Name:WOOD, KELLEEN (PTA)
Entity Type:Individual
Prefix:
First Name:KELLEEN
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BONNER LN
Mailing Address - Street 2:
Mailing Address - City:OFFUTT A F B
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 E SUMMIT ST
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-1709
Practice Address - Country:US
Practice Address - Phone:712-623-5156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-27
Last Update Date:2012-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004842225200000X
NE1057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant