Provider Demographics
NPI:1508064783
Name:BURNESON, KELLY A (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:BURNESON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ONEIL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581
Mailing Address - Country:US
Mailing Address - Phone:508-366-8402
Mailing Address - Fax:
Practice Address - Street 1:40 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02019
Practice Address - Country:US
Practice Address - Phone:508-966-2717
Practice Address - Fax:508-966-2095
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist