Provider Demographics
NPI:1336771153
Name:RIDGE, KELLY (PHYSICAL THERAPY)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RIDGE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SALLITT DR
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666-2279
Mailing Address - Country:US
Mailing Address - Phone:410-604-2162
Mailing Address - Fax:410-604-2975
Practice Address - Street 1:1009 KINDER FARM PARK RD
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1706
Practice Address - Country:US
Practice Address - Phone:240-925-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27854225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist