Provider Demographics
NPI:1003921719
Name:KELLY, BRYAN DAVID (PT, MS)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:DAVID
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 FIRETHORN DR
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-7511
Mailing Address - Country:US
Mailing Address - Phone:845-831-6911
Mailing Address - Fax:
Practice Address - Street 1:185 ROUTE 312
Practice Address - Street 2:SUITE 301B
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-2337
Practice Address - Country:US
Practice Address - Phone:845-279-9288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021446-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQB9941Medicare ID - Type Unspecified