Provider Demographics
NPI:1790052314
Name:BARDOSY, KELLY LYNN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BARDOSY
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 1:3920 N GREEN BAY RD STE 150
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-1416
Mailing Address - Country:US
Mailing Address - Phone:262-321-7164
Mailing Address - Fax:262-314-6051
Practice Address - Street 1:3920 N GREEN BAY RD STE 150
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-1416
Practice Address - Country:US
Practice Address - Phone:262-321-7164
Practice Address - Fax:262-314-6051
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10456-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist