Provider Demographics
NPI:1245554864
Name:DAVIDSON, KELLIE S
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:S
Last Name:DAVIDSON
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 1:420 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:MO
Mailing Address - Zip Code:64730-2058
Mailing Address - Country:US
Mailing Address - Phone:660-679-0653
Mailing Address - Fax:660-200-3010
Practice Address - Street 1:420 S FULTON ST
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:MO
Practice Address - Zip Code:64730-2058
Practice Address - Country:US
Practice Address - Phone:660-679-0653
Practice Address - Fax:660-200-3010
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004023000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist