Provider Demographics
NPI:1972106383
Name:MERRICK, KELLY (PTA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MERRICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 LOCKLEE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-3830
Mailing Address - Country:US
Mailing Address - Phone:502-295-1471
Mailing Address - Fax:
Practice Address - Street 1:227 BROWNS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3215
Practice Address - Country:US
Practice Address - Phone:502-893-2595
Practice Address - Fax:502-893-1811
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01365225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant