Provider Demographics
NPI:1255660213
Name:MIRR, KELLI (LMT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MIRR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 SHERIDAN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2823
Mailing Address - Country:US
Mailing Address - Phone:954-924-8878
Mailing Address - Fax:
Practice Address - Street 1:4921 SHERIDAN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2823
Practice Address - Country:US
Practice Address - Phone:954-924-8878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28886175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 28886OtherLICENSE MASSAGE THERAPIST