Provider Demographics
NPI:1417321340
Name:RAQUET, KELLY (PT, DPT, CLT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RAQUET
Suffix:
Gender:F
Credentials:PT, DPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:DOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07801-1629
Mailing Address - Country:US
Mailing Address - Phone:973-366-4000
Mailing Address - Fax:973-366-4998
Practice Address - Street 1:600 MOUNT PLEASANT AVE
Practice Address - Street 2:SUITE F
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-1629
Practice Address - Country:US
Practice Address - Phone:973-366-4000
Practice Address - Fax:973-366-4998
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039538-1225100000X
NJ40QA01667400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist