Provider Demographics
NPI:1528338514
Name:KELLEN, LAURA MICHELLE (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:KELLEN
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E. YALE LOOP
Mailing Address - Street 2:SUITE 201
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4697
Mailing Address - Country:US
Mailing Address - Phone:949-265-2442
Mailing Address - Fax:949-265-2448
Practice Address - Street 1:250 E. YALE LOOP
Practice Address - Street 2:SUITE 201
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4697
Practice Address - Country:US
Practice Address - Phone:949-265-2442
Practice Address - Fax:949-265-2448
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist