Provider Demographics
NPI:1174620611
Name:DAVIS, KELIE JEAN (DPT)
Entity type:Individual
Prefix:MRS
First Name:KELIE
Middle Name:JEAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELIE
Other - Middle Name:JEAN
Other - Last Name:PODRATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:15 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7611
Mailing Address - Country:US
Mailing Address - Phone:952-933-5085
Mailing Address - Fax:952-931-2159
Practice Address - Street 1:15 8TH AVE N
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:952-933-5085
Practice Address - Fax:952-931-2159
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7809225100000X
MN19372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN046953200Medicaid
MN046953200Medicaid