Provider Demographics
NPI:1275074031
Name:KELLY, TARIQ (ATC)
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:NY
Mailing Address - Zip Code:14744-8732
Mailing Address - Country:US
Mailing Address - Phone:585-567-9563
Mailing Address - Fax:
Practice Address - Street 1:1 WILLARD AVE
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:NY
Practice Address - Zip Code:14744-8732
Practice Address - Country:US
Practice Address - Phone:585-567-9563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003316-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer