Provider Demographics
NPI:1376814509
Name:MATUS, KELLY B (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:MATUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:B
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:115 RIVER FARM DR
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-2145
Mailing Address - Country:US
Mailing Address - Phone:401-398-7894
Mailing Address - Fax:
Practice Address - Street 1:225 CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4533
Practice Address - Country:US
Practice Address - Phone:401-490-7610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02365225100000X
NY012882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist