Provider Demographics
NPI:1962690206
Name:LECKRONE, KELLY OH (DPT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:OH
Last Name:LECKRONE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 S LEMON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1805
Mailing Address - Country:US
Mailing Address - Phone:714-514-2701
Mailing Address - Fax:
Practice Address - Street 1:19032 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2232
Practice Address - Country:US
Practice Address - Phone:714-968-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 340542251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 34054OtherPT LICENSE