Provider Demographics
NPI:1497879969
Name:LIPPERT, KENT (PTA)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:LIPPERT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1154
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1154
Mailing Address - Country:US
Mailing Address - Phone:321-848-2066
Mailing Address - Fax:
Practice Address - Street 1:333 1ST ST N
Practice Address - Street 2:SUITE 2001
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6945
Practice Address - Country:US
Practice Address - Phone:800-920-5038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14121225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant