Provider Demographics
NPI:1861738833
Name:MATTILA, KELLY J (DPT)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:MATTILA
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 1:236 PONDEROSA CT
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-5368
Mailing Address - Country:US
Mailing Address - Phone:303-803-8644
Mailing Address - Fax:
Practice Address - Street 1:236 PONDEROSA CT
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-5368
Practice Address - Country:US
Practice Address - Phone:303-803-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO100872251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics