Provider Demographics
NPI:1285282632
Name:WOODBURY, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WOODBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8160
Mailing Address - Country:US
Mailing Address - Phone:207-621-3639
Mailing Address - Fax:207-626-1827
Practice Address - Street 1:2263 ROUTE 2
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:ME
Practice Address - Zip Code:04401-0605
Practice Address - Country:US
Practice Address - Phone:207-848-9009
Practice Address - Fax:207-404-2562
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist