Basic Information
| Provider Information | |||||||||
| NPI: | 1982991444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4812 E 33RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224126 | ||||||||
| FaxNumber: | 9182702398 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741035002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183820200 | ||||||||
| FaxNumber: | 9183820218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4474 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200034500E | 05 | OK | MEDICAID | 200034500B | 05 | OK | MEDICAID | 200034500C | 05 | OK | MEDICAID | 200034500D | 05 | OK | MEDICAID | 200034500G | 05 | OK | MEDICAID | 200034500F | 05 | OK | MEDICAID | 200034500A | 05 | OK | MEDICAID | 200034500H | 05 | OK | MEDICAID | 200034500I | 05 | OK | MEDICAID |