Provider Demographics
NPI:1295905487
Name:KISHBAUGH, KELLY SUE (MSPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:KISHBAUGH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SUE
Other - Last Name:MOLINARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:722 MOUNT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-7246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 GLENN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1200
Practice Address - Country:US
Practice Address - Phone:570-387-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist