Healthcare Provider Details

I. General information

NPI: 1326238437
Provider Name (Legal Business Name): KELLI MARIE GORMONT MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLI MARIE LAUER MS, ATC

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S ROUTE 36
ROARING SPRING PA
16673-1628
US

IV. Provider business mailing address

5720 OHIO AVE
ALTOONA PA
16602-1145
US

V. Phone/Fax

Practice location:
  • Phone: 814-224-5566
  • Fax:
Mailing address:
  • Phone: 814-940-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003834
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: