1669696852 NPI number — MRS. AMANDA MARLEEN KELSO PT, DPT

Table of content: MRS. AMANDA MARLEEN KELSO PT, DPT (NPI 1669696852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669696852 NPI number — MRS. AMANDA MARLEEN KELSO PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELSO
Provider First Name:
AMANDA
Provider Middle Name:
MARLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PFOST
Provider Other First Name:
AMANDA
Provider Other Middle Name:
MARLEEN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669696852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 MINGES CREEK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49015-4201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-979-6365
Provider Business Mailing Address Fax Number:
269-979-6374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 MINGES CREEK PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49015-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-979-6365
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  PTA 06181 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 5501017783 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)