Provider Demographics
NPI:1417423492
Name:LAUBACH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LAUBACH
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 1:94 RARIG RD
Mailing Address - Street 2:
Mailing Address - City:CATAWISSA
Mailing Address - State:PA
Mailing Address - Zip Code:17820-8661
Mailing Address - Country:US
Mailing Address - Phone:570-204-4116
Mailing Address - Fax:
Practice Address - Street 1:94 RARIG RD
Practice Address - Street 2:
Practice Address - City:CATAWISSA
Practice Address - State:PA
Practice Address - Zip Code:17820-8661
Practice Address - Country:US
Practice Address - Phone:570-204-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC006812L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist