Provider Demographics
NPI:1174658777
Name:WARD-LAWRENCE, KELLY L
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:WARD-LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1002
Mailing Address - Street 2:
Mailing Address - City:POCONO PINES
Mailing Address - State:PA
Mailing Address - Zip Code:18350-1002
Mailing Address - Country:US
Mailing Address - Phone:570-643-5530
Mailing Address - Fax:570-424-2346
Practice Address - Street 1:109 SEVEN BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301
Practice Address - Country:US
Practice Address - Phone:570-643-5530
Practice Address - Fax:570-424-2346
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-012975-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01933364Medicaid