Provider Demographics
NPI:1326238437
Name:GORMONT, KELLI MARIE (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:MARIE
Last Name:GORMONT
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:MARIE
Other - Last Name:LAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC
Mailing Address - Street 1:5720 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-1145
Mailing Address - Country:US
Mailing Address - Phone:814-940-1131
Mailing Address - Fax:
Practice Address - Street 1:401 S ROUTE 36
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673-1628
Practice Address - Country:US
Practice Address - Phone:814-224-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0038342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer