Healthcare Provider Details

I. General information

NPI: 1164555793
Provider Name (Legal Business Name): KELLY D SYKES PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 OLD COLUMBIA RD STE C
COLUMBIA MD
21046-2364
US

IV. Provider business mailing address

10200 OLD COLUMBIA RD STE C
COLUMBIA MD
21046-2364
US

V. Phone/Fax

Practice location:
  • Phone: 410-290-4480
  • Fax: 855-300-3999
Mailing address:
  • Phone: 410-290-4480
  • Fax: 855-300-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number18546
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: