Basic Information
| Provider Information | |||||||||
| NPI: | 1346240025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOTTO | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | MICHELE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1311 ROUTE 100 STE LOWER | ||||||||
| Address2: | |||||||||
| City: | BARTO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 195048724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108455000 | ||||||||
| FaxNumber: | 6108455011 | ||||||||
| Practice Location | |||||||||
| Address1: | 341 10TH AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ROYERSFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194683807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107928100 | ||||||||
| FaxNumber: | 6107921535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT017232 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.