Provider Demographics
NPI:1912161316
Name:TOBIN, KELLY JEAN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:TOBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:CIPALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7231 STATION RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16510-4850
Mailing Address - Country:US
Mailing Address - Phone:814-899-0906
Mailing Address - Fax:814-454-7780
Practice Address - Street 1:1330 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1402
Practice Address - Country:US
Practice Address - Phone:814-459-9300
Practice Address - Fax:814-454-7780
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC005141L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013134050002Medicaid