Provider Demographics
NPI:1962969121
Name:LILLY, CHRISTY L (PTA)
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:L
Last Name:LILLY
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 1:7041 BRONNER CIR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3755
Mailing Address - Country:US
Mailing Address - Phone:814-282-5144
Mailing Address - Fax:
Practice Address - Street 1:9700 STONESTREET RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-2884
Practice Address - Country:US
Practice Address - Phone:502-995-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
KYA03933225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant