Provider Demographics
NPI:1346712486
Name:MERRITT, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MERRITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 COMMONWEALTH AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5940
Mailing Address - Country:US
Mailing Address - Phone:151-846-9587
Mailing Address - Fax:
Practice Address - Street 1:640 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1116
Practice Address - Country:US
Practice Address - Phone:617-497-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA23025OtherPT LICENSE