Healthcare Provider Details

I. General information

NPI: 1699605675
Provider Name (Legal Business Name): KELLY WORMALD DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 WOODMOOR DR STE 106
MONUMENT CO
80132-9098
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 719-694-9747
  • Fax: 719-694-9832
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0021281
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: