Provider Demographics
NPI:1316978182
Name:SANDERS, KELLY MARIE (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:805 AEROVISTA PL
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7919
Practice Address - Country:US
Practice Address - Phone:805-543-7771
Practice Address - Fax:805-543-7761
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABE978ZMedicare PIN
CAWPT 24593 DMedicare ID - Type Unspecified