MEDICARE: MRS. KELLY PRICE PT, DPT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1427442144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY PRICE PT, DPT, ATC

Provider Business Mailing Address
First Line	:	15945 CLAYTON RD STE 210
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-2491
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15945 CLAYTON RD STE 210
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-2491
Country	:	US
Telephone Number	:	636-893-1361
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2015
Last Update Date	:	02/04/2020

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