Provider Demographics
NPI:1356083778
Name:KELLY, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KELLY
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 1:117 DERFUSS LN
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-1609
Mailing Address - Country:US
Mailing Address - Phone:845-570-0771
Mailing Address - Fax:
Practice Address - Street 1:117 DERFUSS LN
Practice Address - Street 2:
Practice Address - City:BLAUVELT
Practice Address - State:NY
Practice Address - Zip Code:10913-1609
Practice Address - Country:US
Practice Address - Phone:845-570-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010932224Z00000X
CT2162224Z00000X
NJ46TA09225300224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant