Provider Demographics
NPI:1891952438
Name:KELM, SUSAN KATHRYN (MPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHRYN
Last Name:KELM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 S BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MARKESAN
Mailing Address - State:WI
Mailing Address - Zip Code:53946-8537
Mailing Address - Country:US
Mailing Address - Phone:920-748-9138
Mailing Address - Fax:
Practice Address - Street 1:933 NEWBURY ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-1730
Practice Address - Country:US
Practice Address - Phone:920-748-9138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40451000Medicaid