Provider Demographics
NPI:1992006761
Name:SADAUCKAS, KELLY P (PT, DPT, OCS, CSCS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:P
Last Name:SADAUCKAS
Suffix:
Gender:F
Credentials:PT, DPT, OCS, CSCS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:P
Other - Last Name:DANKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, CSCS
Mailing Address - Street 1:230 ASHLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5210
Mailing Address - Country:US
Mailing Address - Phone:208-473-6053
Mailing Address - Fax:
Practice Address - Street 1:18 NORTH MAIN ST
Practice Address - Street 2:SUITE 215
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:208-354-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist