Healthcare Provider Details

I. General information

NPI: 1326539610
Provider Name (Legal Business Name): KELLY SAGERMAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY CLANCY DPT

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 S COLLEGE MALL RD STE A
BLOOMINGTON IN
47401-6166
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 812-558-3356
  • Fax: 812-558-3377
Mailing address:
  • Phone: 630-575-6200
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017430
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05013647A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: