Provider Demographics
NPI:1730781303
Name:MOONEY, KELSEY LYNN (DPT)
Entity type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:LYNN
Last Name:MOONEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 SEIKO AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-7815
Mailing Address - Country:US
Mailing Address - Phone:916-765-8264
Mailing Address - Fax:
Practice Address - Street 1:1917 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2704
Practice Address - Country:US
Practice Address - Phone:209-549-4626
Practice Address - Fax:209-549-4625
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist