Provider Demographics
NPI:1245451822
Name:MILLER, KELLY J (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:DECAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:21498 WREN LANDECK ROAD
Mailing Address - Street 2:
Mailing Address - City:VENEDOCIA
Mailing Address - State:OH
Mailing Address - Zip Code:45894-9523
Mailing Address - Country:US
Mailing Address - Phone:419-692-0158
Mailing Address - Fax:
Practice Address - Street 1:1119 WESTWOOD DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1473
Practice Address - Country:US
Practice Address - Phone:888-557-1200
Practice Address - Fax:419-238-3612
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH009124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist