Provider Demographics
NPI:1306982384
Name:WILSON, KELLIE T (MPT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:T
Last Name:WILSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 NE MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4346
Mailing Address - Country:US
Mailing Address - Phone:541-383-8179
Mailing Address - Fax:541-685-2639
Practice Address - Street 1:2115 NE WYATT CT STE 103
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7679
Practice Address - Country:US
Practice Address - Phone:541-382-2070
Practice Address - Fax:541-685-2639
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3074OtherSTATE OF OREGON LICENSE NUMBER
WA207626Medicaid
ORR143400Medicare PIN
WAG8802662Medicare PIN
OR3074OtherSTATE OF OREGON LICENSE NUMBER
WAG8862712Medicare PIN
WAG8802660Medicare PIN