Provider Demographics
NPI:1467765131
Name:CHANG, KELLY MORAN (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MORAN
Last Name:CHANG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 209
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2481
Mailing Address - Country:US
Mailing Address - Phone:518-786-1667
Mailing Address - Fax:518-786-1667
Practice Address - Street 1:989 ROUTE 146
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3646
Practice Address - Country:US
Practice Address - Phone:518-371-5221
Practice Address - Fax:518-371-5378
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60159763225100000X
NY045067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8893505Medicare PIN