=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447685946
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEA ROSE DEVRIES PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2013
-----------------------------------------------------
Last Update Date | 03/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 SHERRY LN STE 201
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-3282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-295-8134
-----------------------------------------------------
Fax | 443-295-8139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5004 SILVERBELL CT
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28409-3697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-720-8527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 35901
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 14277
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 26915
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------