Provider Demographics
NPI:1033718887
Name:DE LA CRUZ, KELLY ANN (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 MIDDLETOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3824
Mailing Address - Country:US
Mailing Address - Phone:860-538-4358
Mailing Address - Fax:
Practice Address - Street 1:2257 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-2328
Practice Address - Country:US
Practice Address - Phone:860-538-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist