Provider Demographics
NPI:1750693115
Name:PARK, KELLEY KATHRYN O'CONNOR (DPT)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:KATHRYN O'CONNOR
Last Name:PARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:KATHRYN
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:454 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-2608
Mailing Address - Country:US
Mailing Address - Phone:650-331-3700
Mailing Address - Fax:650-331-3730
Practice Address - Street 1:1099 D ST STE 105
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2839
Practice Address - Country:US
Practice Address - Phone:415-532-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017799225100000X
CA40661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist