Provider Demographics
NPI:1699964940
Name:TULEY, KENNETH MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:TULEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 JOHNSON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2424
Mailing Address - Country:US
Mailing Address - Phone:336-527-7638
Mailing Address - Fax:336-699-4615
Practice Address - Street 1:700 JOHNSON RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2424
Practice Address - Country:US
Practice Address - Phone:336-527-7638
Practice Address - Fax:336-699-4615
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2716225100000X
NC10878225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist