Provider Demographics
NPI:1386961381
Name:YOUNGBLOOD, KELLI JO (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:JO
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:JO
Other - Last Name:CASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:444 FOUR STATES DR
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:KS
Mailing Address - Zip Code:66739-4324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 FOUR STATES DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-4324
Practice Address - Country:US
Practice Address - Phone:620-783-4111
Practice Address - Fax:620-783-4112
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist