Provider Demographics
NPI:1790054948
Name:KELLEY, DIANA J (LMT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 SILVER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-5007
Mailing Address - Country:US
Mailing Address - Phone:541-282-3496
Mailing Address - Fax:
Practice Address - Street 1:1205 PLAZA BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2683
Practice Address - Country:US
Practice Address - Phone:541-282-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13273173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist