Provider Demographics
NPI:1467503680
Name:NEELLY, KURT R (P T)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:R
Last Name:NEELLY
Suffix:
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 N CUMMINGS LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-2181
Mailing Address - Country:US
Mailing Address - Phone:309-886-2305
Mailing Address - Fax:309-444-3893
Practice Address - Street 1:209 N CUMMINGS LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2181
Practice Address - Country:US
Practice Address - Phone:309-886-2305
Practice Address - Fax:309-444-3893
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0029040291OtherIL BLUE CROSS BLUE SHIELD
IL10759614OtherCAQH PROVIDER ID
L86866Medicare PIN