Provider Demographics
NPI:1326375171
Name:KELLY, GRACE (PTA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 N WALES RD
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1724
Mailing Address - Country:US
Mailing Address - Phone:215-630-1788
Mailing Address - Fax:
Practice Address - Street 1:850 PAPER MILL RD
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-7833
Practice Address - Country:US
Practice Address - Phone:215-233-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-14
Last Update Date:2009-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE000562L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant