Provider Demographics
NPI:1720332083
Name:MOYER, KELSEY CHRISTINE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:CHRISTINE
Last Name:MOYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 4TH AVE N
Mailing Address - Street 2:APARTMENT 18A
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1375
Mailing Address - Country:US
Mailing Address - Phone:320-766-6616
Mailing Address - Fax:
Practice Address - Street 1:4415 W 36 1/2 ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4854
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:952-927-7687
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1619225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant