Provider Demographics
NPI:1992822571
Name:CROGHAN, KELLY M (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CROGHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 DIECKS DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2443
Mailing Address - Country:US
Mailing Address - Phone:270-769-0058
Mailing Address - Fax:270-737-1659
Practice Address - Street 1:106 DIECKS DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2443
Practice Address - Country:US
Practice Address - Phone:270-769-0058
Practice Address - Fax:270-737-1659
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY186517Medicare ID - Type UnspecifiedMEDICARE NUMBER