Healthcare Provider Details

I. General information

NPI: 1588602874
Provider Name (Legal Business Name): KELLY GERRIT VREDEVELD PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 N NAVAJO DR STE A
PRESCOTT VALLEY AZ
86314-4966
US

IV. Provider business mailing address

2852 N NAVAJO DR STE A
PRESCOTT VALLEY AZ
86314-4966
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-9797
  • Fax: 928-772-9340
Mailing address:
  • Phone: 928-772-9797
  • Fax: 928-772-9340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5810
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: