Provider Demographics
NPI:1518532977
Name:MIX, KELSEY ANN (PT, DPT, MS,CMTPT/DN)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:MIX
Suffix:
Gender:F
Credentials:PT, DPT, MS,CMTPT/DN
Other - Prefix:DR
Other - First Name:KELSEY
Other - Middle Name:ANN
Other - Last Name:COOLIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5435 BULL VALLEY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-2209
Mailing Address - Country:US
Mailing Address - Phone:815-451-4502
Mailing Address - Fax:815-977-8467
Practice Address - Street 1:5435 BULL VALLEY RD STE 110
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-2209
Practice Address - Country:US
Practice Address - Phone:815-451-4502
Practice Address - Fax:815-977-8467
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070025867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist