Provider Demographics
NPI:1336461870
Name:SMITH, KELLI LYNN (PT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 140C
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-9787
Mailing Address - Country:US
Mailing Address - Phone:570-265-7688
Mailing Address - Fax:570-265-7134
Practice Address - Street 1:RR 1 BOX 140C
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-9787
Practice Address - Country:US
Practice Address - Phone:570-265-7688
Practice Address - Fax:570-265-7134
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT019644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist