Provider Demographics
NPI:1154032274
Name:WEDWICK, KELSEY R (ATC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:R
Last Name:WEDWICK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7666
Mailing Address - Country:US
Mailing Address - Phone:815-601-3816
Mailing Address - Fax:
Practice Address - Street 1:420 N ILLINOIS RTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-656-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960040942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000009754OtherATHLETIC TRAINING BOARD OF CERTIFICATION