Provider Demographics
NPI:1154710705
Name:EBELL, KELLEY (PTA)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:EBELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 CATTRACK AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-2432
Mailing Address - Country:US
Mailing Address - Phone:402-658-3148
Mailing Address - Fax:
Practice Address - Street 1:2641 CATTRACK AVE
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081
Practice Address - Country:US
Practice Address - Phone:402-658-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-0671225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant