Healthcare Provider Details

I. General information

NPI: 1841676806
Provider Name (Legal Business Name): JUSTIN KELLY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8434 CORCORAN RD
WILLOW SPRINGS IL
60480-1666
US

IV. Provider business mailing address

8434 CORCORAN RD
WILLOW SPRINGS IL
60480-1666
US

V. Phone/Fax

Practice location:
  • Phone: 708-467-0657
  • Fax: 708-330-5046
Mailing address:
  • Phone: 708-467-0657
  • Fax: 708-330-5046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.007134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: