Provider Demographics
NPI:1851958508
Name:WOLF, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1418 TIMBER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-2172
Mailing Address - Country:US
Mailing Address - Phone:608-787-6386
Mailing Address - Fax:
Practice Address - Street 1:19475 SILVER CREEK RD
Practice Address - Street 2:
Practice Address - City:GALESVILLE
Practice Address - State:WI
Practice Address - Zip Code:54630-6400
Practice Address - Country:US
Practice Address - Phone:608-582-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI817-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant