Provider Demographics
NPI:1578651816
Name:KELLY, LORI J (PT)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 SOSCOL AVE STE B191
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-4040
Mailing Address - Country:US
Mailing Address - Phone:707-224-3131
Mailing Address - Fax:707-224-2356
Practice Address - Street 1:433 SOSCOL AVE STE B191
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-4040
Practice Address - Country:US
Practice Address - Phone:707-224-3131
Practice Address - Fax:707-224-2356
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT157570Medicare ID - Type Unspecified