Provider Demographics
NPI:1962696476
Name:ROBERTS, KELLI E (LMT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:E
Last Name:ROBERTS
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 1:2001C CRAWFORDVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327-1019
Mailing Address - Country:US
Mailing Address - Phone:850-926-9171
Mailing Address - Fax:850-926-4172
Practice Address - Street 1:2001C CRAWFORDVILLE HWY
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-1019
Practice Address - Country:US
Practice Address - Phone:850-926-9171
Practice Address - Fax:850-926-4172
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA33987225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2187OtherBLUE CROSS BLUE SHIELD
FLMA33987OtherSTATE OF FLORIDA