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NPI Code Detail

MEDICARE: KELLY MORTLAND PTA

MEDICARE: KELLY MORTLAND PTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy AssistantPTA 20003FL

General Provider Information

NPI Number : 1487875282
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY MORTLAND PTA
Provider Business Mailing Address
First Line : 1155 S ORLANDO AVE
Second Line :
City : WINTER PARK
State : FL
Zip : 32789-4852
Country : US
Telephone Number : 407-539-1792
Fax Number :
Provider Business Practice Location Address
First Line : 1155 S ORLANDO AVE
Second Line :
City : WINTER PARK
State : FL
Zip : 32789-4852
Country : US
Telephone Number : 407-539-1792
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/01/2007
Last Update Date : 07/08/2007

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Directions to “ KELLY MORTLAND PTA” Practice Location

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