Provider Demographics
NPI:1396896163
Name:MACDONALD, KELLY (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-1848
Mailing Address - Country:US
Mailing Address - Phone:415-897-9195
Mailing Address - Fax:415-897-0346
Practice Address - Street 1:246 1ST ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-2636
Practice Address - Country:US
Practice Address - Phone:415-897-9195
Practice Address - Fax:415-897-0346
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist