Provider Demographics
NPI:1174678106
Name:KASSERMAN, KELLY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:KASSERMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 LORI SPENCE
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-2641
Mailing Address - Country:US
Mailing Address - Phone:870-236-8790
Mailing Address - Fax:
Practice Address - Street 1:1910 RECTOR RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-2004
Practice Address - Country:US
Practice Address - Phone:870-240-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2216225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W471OtherBCBS PROVIDER #