Provider Demographics
NPI:1952155327
Name:HIGGINSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HIGGINSON
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 1:129 VIA SAN SEBASTIAN
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1031 AVENIDA PICO STE 201
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6356
Practice Address - Country:US
Practice Address - Phone:949-288-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant