Provider Demographics
NPI:1952446684
Name:WOOLDRIDGE, KELLY LOUISE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LOUISE
Last Name:WOOLDRIDGE
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 1:41 PRESIDENT DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8526
Mailing Address - Country:US
Mailing Address - Phone:636-329-0156
Mailing Address - Fax:
Practice Address - Street 1:1170 TIMBER RUN DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4482
Practice Address - Country:US
Practice Address - Phone:314-469-0606
Practice Address - Fax:314-469-3294
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030161532251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics