Provider Demographics
NPI:1992779797
Name:BURCH, KELLY DILBERT (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DILBERT
Last Name:BURCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7567 CENTRAL PARKE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-6855
Mailing Address - Country:US
Mailing Address - Phone:513-701-6104
Mailing Address - Fax:
Practice Address - Street 1:9395 KENWOOD RD
Practice Address - Street 2:STE. 107
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6819
Practice Address - Country:US
Practice Address - Phone:513-745-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH366632Medicare PIN