Provider Demographics
NPI:1811145659
Name:KELLEY, CARLA RUTHANN (PTA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:RUTHANN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 MILLER DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8091
Mailing Address - Country:US
Mailing Address - Phone:574-941-1055
Mailing Address - Fax:574-941-1083
Practice Address - Street 1:2855 MILLER DR
Practice Address - Street 2:SUITE 105
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8091
Practice Address - Country:US
Practice Address - Phone:574-941-1055
Practice Address - Fax:574-941-1083
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003766A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant