Healthcare Provider Details

I. General information

NPI: 1184976359
Provider Name (Legal Business Name): KELLY STEWART PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HOMER STREET
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

8259 WICKER AVE
SAINT JOHN IN
46373-8878
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8511
  • Fax:
Mailing address:
  • Phone: 219-365-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05007726A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: