Provider Demographics
NPI:1962694299
Name:MCCALL, KELLY MICHELE (MSPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELE
Last Name:MCCALL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 PROCTOR RD
Mailing Address - Street 2:
Mailing Address - City:MOSIER
Mailing Address - State:OR
Mailing Address - Zip Code:97040-9752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-4628
Practice Address - Country:US
Practice Address - Phone:971-206-5102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist