Provider Demographics
NPI:1043731797
Name:PICKENS, KELLY A (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:PICKENS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:HERMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-609-6336
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:7341 OFFICE PARK PL STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-690-6612
Practice Address - Fax:321-690-2630
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012541A225100000X
FLPT31671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT31671OtherPT LICENSURE