Provider Demographics
NPI:1457489940
Name:KLOSTERHOFF, LESA KELLY (PT)
Entity Type:Individual
Prefix:MS
First Name:LESA
Middle Name:KELLY
Last Name:KLOSTERHOFF
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 1:770 LONG REACH RD
Mailing Address - Street 2:
Mailing Address - City:ULLIN
Mailing Address - State:IL
Mailing Address - Zip Code:62992-2250
Mailing Address - Country:US
Mailing Address - Phone:618-845-9362
Mailing Address - Fax:
Practice Address - Street 1:770 LONG REACH RD
Practice Address - Street 2:
Practice Address - City:ULLIN
Practice Address - State:IL
Practice Address - Zip Code:62992-2250
Practice Address - Country:US
Practice Address - Phone:618-845-9362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013962251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics