Provider Demographics
NPI:1669696852
Name:KELSO, AMANDA MARLEEN (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARLEEN
Last Name:KELSO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:MARLEEN
Other - Last Name:PFOST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:75 MINGES CREEK PL
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-4201
Mailing Address - Country:US
Mailing Address - Phone:269-979-6365
Mailing Address - Fax:269-979-6374
Practice Address - Street 1:75 MINGES CREEK PL
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-4201
Practice Address - Country:US
Practice Address - Phone:269-979-6365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 06181225200000X
MI5501017783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH366651Medicare ID - Type UnspecifiedMEDICARE GROUP #
OH0510772Medicaid