Provider Demographics
NPI:1841863958
Name:KELLY-ELLIOTT, GINA (DPT)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:
Last Name:KELLY-ELLIOTT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:319 E MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2520
Mailing Address - Country:US
Mailing Address - Phone:773-414-4397
Mailing Address - Fax:
Practice Address - Street 1:12800 MISSISSIPPI PKWY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-6900
Practice Address - Country:US
Practice Address - Phone:219-662-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011844A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist