Provider Demographics
NPI:1235103623
Name:KLUCHUROSKY, LISA KATHRYN (AT,C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KATHRYN
Last Name:KLUCHUROSKY
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7816 LANETTA LN
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CHILDREN'S SPORTS MEDICINE
Practice Address - Street 2:479 PARSONS AVENUE
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5577
Practice Address - Country:US
Practice Address - Phone:614-722-5573
Practice Address - Fax:614-722-5581
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0000822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer