Provider Demographics
NPI:1700487212
Name:VONDERHEIDE, KELLEY M (DPT)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:VONDERHEIDE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:M
Other - Last Name:AUFFART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 11TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:TELL CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47586-2130
Mailing Address - Country:US
Mailing Address - Phone:812-547-7770
Mailing Address - Fax:812-547-7784
Practice Address - Street 1:255 W 36TH ST STE 100
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-7850
Practice Address - Country:US
Practice Address - Phone:812-482-7755
Practice Address - Fax:812-482-7757
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013795A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05013795AOtherPHYSICAL THERAPY LICENSE