Provider Demographics
NPI:1114077476
Name:CORMAN, KELLIE D (LMT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:D
Last Name:CORMAN
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 1:5843 ELLIOTT RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0401
Mailing Address - Country:US
Mailing Address - Phone:337-478-0834
Mailing Address - Fax:
Practice Address - Street 1:5843 ELLIOTT RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-0401
Practice Address - Country:US
Practice Address - Phone:337-478-0834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA0232-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LALA0232-01OtherMASSAGE THERAPY LICENSE