Provider Demographics
NPI:1770895989
Name:KJELLSTROM, KENT J (MPT)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:J
Last Name:KJELLSTROM
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7733 FORSYTH BLVD STE 2300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1806
Mailing Address - Country:US
Mailing Address - Phone:800-677-1202
Mailing Address - Fax:
Practice Address - Street 1:900 N 3RD ST
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1666
Practice Address - Country:US
Practice Address - Phone:815-562-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2010-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist