Provider Demographics
NPI:1134120116
Name:KELLY, LISA (PT,CERTMDT,COMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT,CERTMDT,COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1436
Mailing Address - Country:US
Mailing Address - Phone:610-724-8708
Mailing Address - Fax:
Practice Address - Street 1:420 BAINBRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1568
Practice Address - Country:US
Practice Address - Phone:215-629-1270
Practice Address - Fax:215-629-5531
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT009484-L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT009484-LOtherPT LICENSE NUMBER