Provider Demographics
NPI:1528134608
Name:DHOM, KELI J (PT)
Entity type:Individual
Prefix:
First Name:KELI
Middle Name:J
Last Name:DHOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:19460 E 1150TH AVE
Mailing Address - Street 2:
Mailing Address - City:DIETERICH
Mailing Address - State:IL
Mailing Address - Zip Code:62424-2150
Mailing Address - Country:US
Mailing Address - Phone:217-821-0542
Mailing Address - Fax:217-925-5356
Practice Address - Street 1:19460 E 1150TH AVE
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424-2150
Practice Address - Country:US
Practice Address - Phone:217-821-0542
Practice Address - Fax:217-925-5356
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist