Provider Demographics
NPI:1326450073
Name:KELLY, EDWARD M (PTA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
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Mailing Address - Street 1:3433 ROUTE 446
Mailing Address - Street 2:
Mailing Address - City:ELDRED
Mailing Address - State:PA
Mailing Address - Zip Code:16731-3109
Mailing Address - Country:US
Mailing Address - Phone:814-225-4980
Mailing Address - Fax:
Practice Address - Street 1:11039 DUGWAY RD
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:NY
Practice Address - Zip Code:14735-8610
Practice Address - Country:US
Practice Address - Phone:585-567-2232
Practice Address - Fax:585-567-2239
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY004576-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant