Provider Demographics
NPI:1295144095
Name:STRUBBERG, KELLI (LPTA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:STRUBBERG
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 SIGNAL RD
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-3122
Mailing Address - Country:US
Mailing Address - Phone:423-208-1960
Mailing Address - Fax:
Practice Address - Street 1:1104 SIGNAL RD
Practice Address - Street 2:
Practice Address - City:SIGNAL MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37377-3122
Practice Address - Country:US
Practice Address - Phone:423-208-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5360172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker