Provider Demographics
NPI:1083221949
Name:KELLY, JAMES EDWARD JR (OTR/L)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FORT BROWN DR APT 201
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12903-4906
Mailing Address - Country:US
Mailing Address - Phone:516-220-3593
Mailing Address - Fax:
Practice Address - Street 1:45 MONTCALM ST
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-1343
Practice Address - Country:US
Practice Address - Phone:518-585-6230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024702225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist