Basic Information
| Provider Information | |||||||||
| NPI: | 1659383867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELSICK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | M.S.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 43RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 W VAN DORN ST., | ||||||||
| Address2: | STE D | ||||||||
| City: | POLK CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502260142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159846377 | ||||||||
| FaxNumber: | 5159846782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 04/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 03561 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 03561 | 01 | IA | PHYSICAL THERAPY LICENSE | OTHER |