Healthcare Provider Details

I. General information

NPI: 1285901884
Provider Name (Legal Business Name): AMY J KELLER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2011
Last Update Date: 11/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 E MOORES PIKE
BLOOMINGTON IN
47401-7129
US

IV. Provider business mailing address

8279 S STONE RIDGE RD
BLOOMINGTON IN
47401-9037
US

V. Phone/Fax

Practice location:
  • Phone: 812-334-7604
  • Fax: 812-334-7705
Mailing address:
  • Phone: 812-824-4808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001615A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: