Provider Demographics
NPI:1043649239
Name:KELLY, DEREK (PT/AOP)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT/AOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 MEADOWRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-1214
Mailing Address - Country:US
Mailing Address - Phone:704-999-4734
Mailing Address - Fax:
Practice Address - Street 1:3800 SHAMROCK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-3220
Practice Address - Country:US
Practice Address - Phone:704-532-5462
Practice Address - Fax:704-532-5387
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist