Basic Information
| Provider Information | |||||||||
| NPI: | 1083646061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERL | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEMELLE | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3601 30TH AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626570222 | ||||||||
| FaxNumber: | 2626577190 | ||||||||
| Practice Location | |||||||||
| Address1: | 3921 30TH AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629250311 | ||||||||
| FaxNumber: | 2626522370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070014256 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10212024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40449700 | 05 | WI | MEDICAID | P00169801 | 01 | WI | RAILROAD MEDICARE NUMBER | OTHER |