Provider Demographics
NPI:1326644238
Name:FREESE, KELLIE LEIGH (CMT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LEIGH
Last Name:FREESE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DEL TORINO
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-0204
Mailing Address - Country:US
Mailing Address - Phone:951-515-9026
Mailing Address - Fax:
Practice Address - Street 1:1 DEL TORINO
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-0204
Practice Address - Country:US
Practice Address - Phone:951-515-9026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76758225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist