Provider Demographics
NPI:1306573225
Name:KELLY, MACKENZIE (DPT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:GULLICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
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:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:1013 W UNIVERSITY AVE STE 335
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-5343
Practice Address - Country:US
Practice Address - Phone:512-876-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist