Provider Demographics
NPI:1326595760
Name:WHITON, KELLIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:WHITON
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:CELESTE
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:169 N GATEWAY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9805
Mailing Address - Country:US
Mailing Address - Phone:435-701-7010
Mailing Address - Fax:435-701-7012
Practice Address - Street 1:169 N GATEWAY DR STE 210
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9805
Practice Address - Country:US
Practice Address - Phone:435-701-7010
Practice Address - Fax:435-701-7012
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4362225100000X
UT14139363-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4327020Medicaid