Provider Demographics
NPI:1750656229
Name:GREGERSON, KELLY L (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:GREGERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:LIPOUFSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5131 W MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-8880
Mailing Address - Country:US
Mailing Address - Phone:559-679-1889
Mailing Address - Fax:
Practice Address - Street 1:5131 W MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-8880
Practice Address - Country:US
Practice Address - Phone:559-679-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-17
Last Update Date:2012-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT139492251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics