Provider Demographics
NPI:1871874099
Name:HARLEY, KELLI LEANN (PTA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LEANN
Last Name:HARLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 MARVIN HANCOCK DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-3479
Mailing Address - Country:US
Mailing Address - Phone:409-384-7041
Mailing Address - Fax:409-384-7064
Practice Address - Street 1:296 MARVIN HANCOCK DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-3479
Practice Address - Country:US
Practice Address - Phone:409-384-7041
Practice Address - Fax:409-384-7064
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2071567225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant