Provider Demographics
NPI:1144432881
Name:PATTON-COOK, KELLY SUE (PTA,LMT)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:SUE
Last Name:PATTON-COOK
Suffix:
Gender:F
Credentials:PTA,LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1946
Mailing Address - Country:US
Mailing Address - Phone:419-960-7195
Mailing Address - Fax:419-960-7195
Practice Address - Street 1:514 MADISON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1946
Practice Address - Country:US
Practice Address - Phone:419-960-7195
Practice Address - Fax:419-960-7195
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 2970225200000X
OH8425225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36-4607517OtherEIN