Provider Demographics
NPI:1528424181
Name:WHITTAKER, KELLY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-5081
Mailing Address - Country:US
Mailing Address - Phone:270-781-1151
Mailing Address - Fax:270-781-1959
Practice Address - Street 1:542 THREE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-7589
Practice Address - Country:US
Practice Address - Phone:270-781-1151
Practice Address - Fax:270-781-1959
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT006087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist