Provider Demographics
NPI:1336336197
Name:KELLY, LISA A (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 N REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-0709
Mailing Address - Country:US
Mailing Address - Phone:419-578-4357
Mailing Address - Fax:419-578-6918
Practice Address - Street 1:2526 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-0709
Practice Address - Country:US
Practice Address - Phone:419-578-4357
Practice Address - Fax:419-578-6918
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 002979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2645794Medicaid
OH2645794Medicaid