Provider Demographics
NPI:1972762714
Name:KELLEY, DWAIN E (PT)
Entity type:Individual
Prefix:
First Name:DWAIN
Middle Name:E
Last Name:KELLEY
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 1:10127 WEDD DR
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-5443
Mailing Address - Country:US
Mailing Address - Phone:913-438-2775
Mailing Address - Fax:
Practice Address - Street 1:10300 W 103RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212
Practice Address - Country:US
Practice Address - Phone:913-894-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1062225100000X
KS1101441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS11-01441OtherSTATE PT LICENSE
MOR1062OtherSTATE PT LICENSE