Provider Demographics
NPI:1790158954
Name:WHITNEY-BABCOCK, KELLY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHITNEY-BABCOCK
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 W ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2950
Mailing Address - Country:US
Mailing Address - Phone:916-880-8276
Mailing Address - Fax:
Practice Address - Street 1:1001 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1590
Practice Address - Country:US
Practice Address - Phone:916-880-8276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002479A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer