MEDICARE: STEPHANIE JANE KELSICK M.S.P.T.

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	225100000X	Physical Therapist	03561	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	03561	OTHER	IA	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1659383867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE JANE KELSICK M.S.P.T.

Provider Business Mailing Address
First Line	:	850 43RD AVE STE 100
Second Line	:
City	:	MOLINE
State	:	IL
Zip	:	61265-8401
Country	:	US
Telephone Number	:	309-743-2070
Fax Number	:	309-743-2073

Provider Business Practice Location Address
First Line	:	212 W VAN DORN ST.,
Second Line	:	STE D
City	:	POLK CITY
State	:	IA
Zip	:	50226-0142
Country	:	US
Telephone Number	:	515-984-6377
Fax Number	:	515-984-6782

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

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	04/12/2012

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