Provider Demographics
NPI:1376056903
Name:KELLEY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3383 BRADFORD LN
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-3779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ARBOR TER
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3900
Practice Address - Country:US
Practice Address - Phone:636-343-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist