Provider Demographics
NPI:1912599382
Name:PEDERSON, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 S RICE RD
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-3404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4960 VERDUGO WAY
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8632
Practice Address - Country:US
Practice Address - Phone:805-765-4773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist