Provider Demographics
NPI:1982884672
Name:DIRECTO, KELLY LEE (RPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:DIRECTO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEE
Other - Last Name:NEET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5691
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:27924 SECO CANYON RD
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91350-3870
Practice Address - Country:US
Practice Address - Phone:661-513-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP260ZMedicare PIN