Provider Demographics
NPI:1740410430
Name:BARRY, KELLI JEANETTE
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:JEANETTE
Last Name:BARRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39196 S SUGAR LN
Mailing Address - Street 2:
Mailing Address - City:COHASSET
Mailing Address - State:MN
Mailing Address - Zip Code:55721-8505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39196 S SUGAR LN
Practice Address - Street 2:
Practice Address - City:COHASSET
Practice Address - State:MN
Practice Address - Zip Code:55721-8505
Practice Address - Country:US
Practice Address - Phone:218-360-3363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist