Healthcare Provider Details

I. General information

NPI: 1073721213
Provider Name (Legal Business Name): KELLI KAY HORTON ANDERSON PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 07/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

IV. Provider business mailing address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-7606
  • Fax:
Mailing address:
  • Phone: 605-698-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7144
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1950
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1203
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: