Provider Demographics
NPI:1760834154
Name:FARRELL MOFFITT, KELLY COLLEEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:COLLEEN
Last Name:FARRELL MOFFITT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:COLLEEN
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2600 N. WYATT DR.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6106
Mailing Address - Country:US
Mailing Address - Phone:520-324-3027
Mailing Address - Fax:520-324-3128
Practice Address - Street 1:2600 N. WYATT DR.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6106
Practice Address - Country:US
Practice Address - Phone:520-324-3027
Practice Address - Fax:520-324-3128
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014057225100000X
AZLPT-012573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ552763Medicaid