Provider Demographics
NPI:1710046503
Name:HIDALGO, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HIDALGO
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 1:122 STROTHER PL
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1876
Mailing Address - Country:US
Mailing Address - Phone:678-463-6621
Mailing Address - Fax:912-466-7233
Practice Address - Street 1:122 STROTHER PL
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1876
Practice Address - Country:US
Practice Address - Phone:678-463-6621
Practice Address - Fax:912-466-7233
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7123225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000937087CMedicaid
GA000937087AMedicaid
GA7123OtherPHYSICAL THERPAY LICENSE