Provider Demographics
NPI:1437395480
Name:JIMKELLY, MERCY TABY (MA)
Entity Type:Individual
Prefix:MS
First Name:MERCY
Middle Name:TABY
Last Name:JIMKELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MERCY
Other - Middle Name:TABY
Other - Last Name:SUVEEHARAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:13949 85TH DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:718-739-0623
Mailing Address - Fax:
Practice Address - Street 1:13949 85TH DRIVE
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435
Practice Address - Country:US
Practice Address - Phone:718-739-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013587-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist