Provider Demographics
NPI:1447861703
Name:BLACK, KELLI FACUNDUS (LMT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:FACUNDUS
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RATTLING HORNS LN
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:MT
Mailing Address - Zip Code:59859-9613
Mailing Address - Country:US
Mailing Address - Phone:570-637-1122
Mailing Address - Fax:
Practice Address - Street 1:195 BOYER ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:MT
Practice Address - Zip Code:59859-5985
Practice Address - Country:US
Practice Address - Phone:570-637-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-18465225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist