Provider Demographics
NPI:1053036301
Name:KELSON, GARRETT (ATC)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:KELSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:IL
Mailing Address - Zip Code:61732-9330
Mailing Address - Country:US
Mailing Address - Phone:309-242-1242
Mailing Address - Fax:
Practice Address - Street 1:302 E PARK ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:IL
Practice Address - Zip Code:61732-9330
Practice Address - Country:US
Practice Address - Phone:309-242-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0045582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer