Provider Demographics
NPI:1801843867
Name:KELLER, LISA M (MPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1501
Mailing Address - Country:US
Mailing Address - Phone:330-618-0285
Mailing Address - Fax:330-336-8731
Practice Address - Street 1:136 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1501
Practice Address - Country:US
Practice Address - Phone:330-618-0285
Practice Address - Fax:330-230-7443
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH009824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH358260OtherANTHEM
OH2310743Medicaid
OH$$$$$$$$$010OtherMEDICAL MUTUAL
OH2310743Medicaid
OH$$$$$$$$$-00OtherWORKERS COMP