Provider Demographics
NPI:1891313342
Name:KETELSEN, KELSEY LYN (PT, MSPT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYN
Last Name:KETELSEN
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 TOPAZ ST
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3445
Mailing Address - Country:US
Mailing Address - Phone:307-679-4894
Mailing Address - Fax:
Practice Address - Street 1:621 TOPAZ ST
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-3445
Practice Address - Country:US
Practice Address - Phone:307-679-4894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1326976225100000X
NC19316225100000X
VA2305212668225100000X
CO0016556225100000X
WY0999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist