=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205258787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY HOLDEN PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2014
-----------------------------------------------------
Last Update Date | 05/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 SCHOOL DR
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-2099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-334-0705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 SCHOOL DR
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-2099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-334-0705
-----------------------------------------------------
Fax | 330-334-0711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 012100
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------