MEDICARE: MRS. KELLY SOUTHARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1953	SC

General Provider Information

NPI Number	:	1114145653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY SOUTHARD

Provider Business Mailing Address
First Line	:	300 DUNHILL DR
Second Line	:
City	:	ANDERSON
State	:	SC
Zip	:	29625-5209
Country	:	US
Telephone Number	:	864-375-1235
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 ANDERSON RD STE C
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-7651
Country	:	US
Telephone Number	:	864-295-9890
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2007
Last Update Date	:	07/08/2007

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