Provider Demographics
NPI:1841679867
Name:SCOVILLE, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SCOVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:DIANE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-954-7408
Practice Address - Street 1:4929 PEAVINE RD
Practice Address - Street 2:STE 101
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38571-7994
Practice Address - Country:US
Practice Address - Phone:931-484-7442
Practice Address - Fax:931-484-7994
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist