Provider Demographics
NPI:1508173253
Name:DAVIS, KELLY L (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:BEDARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 2868
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0259
Mailing Address - Country:US
Mailing Address - Phone:518-562-7075
Mailing Address - Fax:518-562-7933
Practice Address - Street 1:176 TOM MILLER RD
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6426
Practice Address - Country:US
Practice Address - Phone:518-562-4616
Practice Address - Fax:518-562-7918
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist