Provider Demographics
NPI:1003640715
Name:KELLEY, DESTRY BROOK (DPT)
Entity type:Individual
Prefix:
First Name:DESTRY
Middle Name:BROOK
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 S HARVARD AVE APT K
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3545
Mailing Address - Country:US
Mailing Address - Phone:580-243-7250
Mailing Address - Fax:
Practice Address - Street 1:3300 OK-97 STE 200
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063
Practice Address - Country:US
Practice Address - Phone:539-527-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist