Provider Demographics
NPI:1467753970
Name:ELLER, LORI KATHLEEN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:KATHLEEN
Last Name:ELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:KATHLEEN
Other - Last Name:KIMBALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ITDS
Mailing Address - Street 1:1175 SW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-6761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1175 SW 18TH ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-6761
Practice Address - Country:US
Practice Address - Phone:954-554-8847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist