Provider Demographics
NPI:1710193305
Name:POOLE, KELLY GLASCO (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:GLASCO
Last Name:POOLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3651 MARS HILL RD STE 350A
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-8501
Mailing Address - Country:US
Mailing Address - Phone:706-389-5199
Mailing Address - Fax:706-723-7081
Practice Address - Street 1:3651 MARS HILL RD STE 350A
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-8501
Practice Address - Country:US
Practice Address - Phone:706-389-5199
Practice Address - Fax:706-723-7081
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist