Provider Demographics
NPI:1851711436
Name:VALENTINE, KELLY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:VALENTINE
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 1:27 BROOKEBURY DR APT B1
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-2937
Mailing Address - Country:US
Mailing Address - Phone:410-905-7253
Mailing Address - Fax:
Practice Address - Street 1:27 BROOKEBURY DR APT B1
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-2937
Practice Address - Country:US
Practice Address - Phone:410-905-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA 3421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant