Basic Information
| Provider Information | |||||||||
| NPI: | 1730781303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 SEIKO AVE | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952407815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167658264 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1917 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095494626 | ||||||||
| FaxNumber: | 2095494625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2020 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 299486 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.