Provider Demographics
NPI:1104336916
Name:WEATHERBY, KELLY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WEATHERBY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ALEXANDER
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JUST GOT MARRIED
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11019 CANYON RD E STE C
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3001
Practice Address - Country:US
Practice Address - Phone:253-286-3600
Practice Address - Fax:253-286-3444
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist