Provider Demographics
NPI:1861551640
Name:MITCHELL, KELLEY KYBURZ (PT)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:KYBURZ
Last Name:MITCHELL
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2739
Mailing Address - Country:US
Mailing Address - Phone:770-728-8833
Mailing Address - Fax:678-668-7469
Practice Address - Street 1:4005 CANTON RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-2739
Practice Address - Country:US
Practice Address - Phone:770-728-8833
Practice Address - Fax:678-668-7469
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5199225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5199OtherPHYSICAL THERAPY LICENSE