Provider Demographics
NPI:1225335144
Name:KELLIM, LISA J (LMT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:J
Last Name:KELLIM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1508
Mailing Address - Street 2:
Mailing Address - City:KAMIAH
Mailing Address - State:ID
Mailing Address - Zip Code:83536-8500
Mailing Address - Country:US
Mailing Address - Phone:208-935-7702
Mailing Address - Fax:280-935-1728
Practice Address - Street 1:1102 3RD ST
Practice Address - Street 2:
Practice Address - City:KAMIAH
Practice Address - State:ID
Practice Address - Zip Code:83536-5333
Practice Address - Country:US
Practice Address - Phone:208-935-7702
Practice Address - Fax:208-935-1728
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-05752225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist