Provider Demographics
NPI:1720350853
Name:HERNDON, KELLEY WOOD (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:WOOD
Last Name:HERNDON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:MARIE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7601 PARKLANE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6122
Mailing Address - Country:US
Mailing Address - Phone:803-741-9090
Mailing Address - Fax:803-741-7216
Practice Address - Street 1:7601 PARKLANE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6122
Practice Address - Country:US
Practice Address - Phone:803-741-9090
Practice Address - Fax:803-741-7216
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2723S225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant