Provider Demographics
NPI:1912263815
Name:HALEY, KELLY (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 HUNT DR APT A
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6117
Mailing Address - Country:US
Mailing Address - Phone:407-506-8376
Mailing Address - Fax:
Practice Address - Street 1:7130 HORTON FIELDHOUSE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790
Practice Address - Country:US
Practice Address - Phone:309-438-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0024822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer