Individual
KELLIE T WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MPT
Contact information
Practice address
2115 NE WYATT CT STE 103, BEND, OR 97701-7679
(541) 382-2070
(541) 685-2639
Mailing address
330 NE MARSHALL AVE, BEND, OR 97701-4346
(541) 383-8179
(541) 685-2639
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
207626
—
WA
01
—
3074
STATE OF OREGON LICENSE NUMBER
OR
Enumeration date
01/29/2007
Last updated
02/15/2022
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