Provider Demographics
NPI:1508019076
Name:KELLY, LISA JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JEAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 S BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19363-1192
Mailing Address - Country:US
Mailing Address - Phone:610-998-9308
Mailing Address - Fax:
Practice Address - Street 1:325 S BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:PA
Practice Address - Zip Code:19363-1192
Practice Address - Country:US
Practice Address - Phone:610-998-9308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE000715L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant