Provider Demographics
NPI:1629353313
Name:LALLY, KRISTA RAE (PT)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:RAE
Last Name:LALLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:RAE
Other - Last Name:PETRUSKEVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-862-3001
Mailing Address - Fax:484-862-3013
Practice Address - Street 1:707 HAMILTON ST FL 4
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18101-2407
Practice Address - Country:US
Practice Address - Phone:484-862-3001
Practice Address - Fax:484-862-3013
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT021647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist