Provider Demographics
NPI:1790161834
Name:LETZ, KALLI
Entity type:Individual
Prefix:
First Name:KALLI
Middle Name:
Last Name:LETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10700 PARK PL
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8666
Practice Address - Country:US
Practice Address - Phone:219-351-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007096225200000X
IN06006280A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant