Provider Demographics
NPI:1619418126
Name:KELLERMAN, CLAYTON (PTA)
Entity type:Individual
Prefix:MR
First Name:CLAYTON
Middle Name:
Last Name:KELLERMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12528 S ACUFF CT
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-5984
Mailing Address - Country:US
Mailing Address - Phone:785-393-3673
Mailing Address - Fax:
Practice Address - Street 1:1615 PARKER AVE
Practice Address - Street 2:
Practice Address - City:OSAWATOMIE
Practice Address - State:KS
Practice Address - Zip Code:66064-1703
Practice Address - Country:US
Practice Address - Phone:913-755-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02341225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant