Provider Demographics
NPI:1295081354
Name:GOSSMAN, KELLIE S (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:S
Last Name:GOSSMAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:S
Other - Last Name:WILKINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2402 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68849-4510
Mailing Address - Country:US
Mailing Address - Phone:308-865-1143
Mailing Address - Fax:
Practice Address - Street 1:620 E 25TH ST STE 7
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5529
Practice Address - Country:US
Practice Address - Phone:308-455-1781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3099225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47077636832Medicaid