Provider Demographics
NPI:1194708115
Name:BUSHORE, KELLY LEE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:BUSHORE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E PLANK RD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602
Mailing Address - Country:US
Mailing Address - Phone:814-941-7708
Mailing Address - Fax:814-941-7715
Practice Address - Street 1:401 RTE 36 SOUTH
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673
Practice Address - Country:US
Practice Address - Phone:814-224-5566
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015724225100000X
PADAPT000019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1438404OtherHIGHMARK
P76494Medicare UPIN
PA065748PRYMedicare ID - Type Unspecified