Provider Demographics
NPI:1780017665
Name:LINDBERG, KELLY JEAN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:LINDBERG
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 1:1003 ISANTI PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-7507
Mailing Address - Country:US
Mailing Address - Phone:612-280-7176
Mailing Address - Fax:
Practice Address - Street 1:1003 ISANTI PKWY NW
Practice Address - Street 2:
Practice Address - City:ISANTI
Practice Address - State:MN
Practice Address - Zip Code:55040-7507
Practice Address - Country:US
Practice Address - Phone:612-280-7176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA443225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant