Provider Demographics
NPI:1083074785
Name:MINTZ, KELLY ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:MINTZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PARMELEE DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-3426
Mailing Address - Country:US
Mailing Address - Phone:330-618-9695
Mailing Address - Fax:
Practice Address - Street 1:1660 AKRON PENINSULA RD
Practice Address - Street 2:SUITE101A
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5189
Practice Address - Country:US
Practice Address - Phone:330-618-9695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.022407 L-M225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH33.022407OtherSTATE MEDICAL BOARD OF OHIO