MEDICARE: KELSEY SHUPP PT, DPT

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	225100000X	Physical Therapist	2016023765	MO

General Provider Information

NPI Number	:	1811644636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY SHUPP PT, DPT

Provider Business Mailing Address
First Line	:	121 CHESTERFIELD TOWNE CTR
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63005-1230
Country	:	US
Telephone Number	:	636-730-1601
Fax Number	:

Provider Business Practice Location Address
First Line	:	121 CHESTERFIELD TOWNE CTR
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63005-1230
Country	:	US
Telephone Number	:	636-730-1601
Fax Number	:

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

Provider Enumeration Date	:	03/02/2022
Last Update Date	:	03/02/2022

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