Provider Demographics
NPI:1265298640
Name:WHETHAM, KELLY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHETHAM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CIRCLE 75 PKWY SE STE 1400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12201 HIGHWAY 92 STE D
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7141
Practice Address - Country:US
Practice Address - Phone:470-632-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist