Provider Demographics
NPI:1699259614
Name:GERAGHTY, KELLY A (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:GERAGHTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 S BOUNDARY AVE
Practice Address - Street 2:
Practice Address - City:PROCTOR
Practice Address - State:MN
Practice Address - Zip Code:55810-2306
Practice Address - Country:US
Practice Address - Phone:218-576-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist