Provider Demographics
NPI:1982991444
Name:KELLEY, JOSHUA (DPT)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2038
Mailing Address - Country:US
Mailing Address - Phone:918-622-4126
Mailing Address - Fax:918-270-2398
Practice Address - Street 1:119 E 4TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74103-5002
Practice Address - Country:US
Practice Address - Phone:918-382-0200
Practice Address - Fax:918-382-0218
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200034500EMedicaid
OK200034500BMedicaid
OK200034500CMedicaid
OK200034500DMedicaid
OK200034500GMedicaid
OK200034500FMedicaid
OK200034500AMedicaid
OK200034500HMedicaid
OK200034500IMedicaid
OK200034500IMedicaid