Provider Demographics
NPI:1225368772
Name:EADY, KELLI (MA, LMT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:EADY
Suffix:
Gender:F
Credentials:MA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-2942
Mailing Address - Country:US
Mailing Address - Phone:407-423-0038
Mailing Address - Fax:
Practice Address - Street 1:3541 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-2942
Practice Address - Country:US
Practice Address - Phone:407-423-0038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA55970225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist