Provider Demographics
NPI:1609098011
Name:BRIZZOLARA, KELLI JO (PT, OCS)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:JO
Last Name:BRIZZOLARA
Suffix:
Gender:F
Credentials:PT, OCS
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 670769
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75367-0769
Mailing Address - Country:US
Mailing Address - Phone:214-239-0990
Mailing Address - Fax:214-239-0991
Practice Address - Street 1:7115 GREENVILLE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5100
Practice Address - Country:US
Practice Address - Phone:214-239-0990
Practice Address - Fax:214-239-0991
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11537512251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T7997OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX8K5997Medicare PIN