=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376991083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLEY K HAGA L.P.T.A., A.T.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2016
-----------------------------------------------------
Last Update Date | 06/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1152 SNIDER ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24354-4216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-782-9696
-----------------------------------------------------
Fax | 276-782-9886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 624 MUSSERS MILL RD
-----------------------------------------------------
City | CROCKETT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24323-3039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-686-5491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2306601430
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 0126000330
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------