Provider Demographics
NPI:1205946191
Name:HAAG, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HAAG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 OLD SEMINARY RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-7705
Mailing Address - Country:US
Mailing Address - Phone:931-728-8601
Mailing Address - Fax:
Practice Address - Street 1:1802 N JACKSON ST
Practice Address - Street 2:SUITE 820
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8218
Practice Address - Country:US
Practice Address - Phone:931-455-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2279OtherLICENSE #