Provider Demographics
NPI:1053447102
Name:KELTY, LISA ANN (PT, MHS)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:KELTY
Suffix:
Gender:F
Credentials:PT, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1043
Mailing Address - Country:US
Mailing Address - Phone:815-663-5029
Mailing Address - Fax:815-663-2101
Practice Address - Street 1:4 OAK RIDGE DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1043
Practice Address - Country:US
Practice Address - Phone:815-663-5029
Practice Address - Fax:815-663-2101
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist