Provider Demographics
NPI:1134100126
Name:KELLY, GARY L (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:19510 VENTURA BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-996-1725
Mailing Address - Fax:818-996-0210
Practice Address - Street 1:1605 E PALMDALE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550
Practice Address - Country:US
Practice Address - Phone:661-273-5333
Practice Address - Fax:661-273-0033
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT7963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT7963Medicare ID - Type Unspecified