Provider Demographics
NPI:1326115841
Name:RUSSO, KELLY A (PT, DPT, NCS, ATP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PT, DPT, NCS, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 TUCKER DR
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-1457
Mailing Address - Country:US
Mailing Address - Phone:443-739-6993
Mailing Address - Fax:
Practice Address - Street 1:414 PAOLI PIKE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3311
Practice Address - Country:US
Practice Address - Phone:484-596-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2251N0400X
MD202852251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology