Provider Demographics
NPI:1316963036
Name:KELSEY, THERESA L (LPT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:KELSEY
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 AMSTER GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-8073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 FRONTIER BLVD STE 106
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484
Practice Address - Country:US
Practice Address - Phone:606-257-0005
Practice Address - Fax:606-262-4132
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100508700Medicaid
KY0985002Medicare ID - Type UnspecifiedMEDICARE #