Provider Demographics
NPI:1124253596
Name:BAKER, KELLY ANN (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BAKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:HORVATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:5100 BRADENTON AVE STE D
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017
Practice Address - Country:US
Practice Address - Phone:614-799-0601
Practice Address - Fax:614-799-0667
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019626225100000X
IN05009941A225100000X
OHPT017329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201055560Medicaid
IN201055560Medicaid
IN214690ZMedicare PIN
INM400052231Medicare PIN
IN214710ZMedicare PIN