Healthcare Provider Details

I. General information

NPI: 1124931571
Provider Name (Legal Business Name): KELLIE GREENOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 MOORGATE DR
LOVELAND CO
80538-5213
US

IV. Provider business mailing address

2465 MOORGATE DR
LOVELAND CO
80538-5213
US

V. Phone/Fax

Practice location:
  • Phone: 845-325-1096
  • Fax:
Mailing address:
  • Phone: 845-325-1096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0015272
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: