Provider Demographics
NPI:1154358323
Name:MCCOOK, KELLY HEATH (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:HEATH
Last Name:MCCOOK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5028 FURMAN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206
Mailing Address - Country:US
Mailing Address - Phone:803-782-0139
Mailing Address - Fax:
Practice Address - Street 1:1612 MARION ST
Practice Address - Street 2:SUITE 113
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-253-6721
Practice Address - Fax:803-799-8177
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ325126945Medicare PIN