Provider Demographics
NPI:1104711951
Name:KELLY, THERESA (PT, DPT, MS ED)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT, DPT, MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 OAKLEY WAY
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3015
Mailing Address - Country:US
Mailing Address - Phone:973-332-1377
Mailing Address - Fax:
Practice Address - Street 1:800 E GATE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2105
Practice Address - Country:US
Practice Address - Phone:973-332-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA005385002251P0200X, 225100000X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics