Provider Demographics
NPI:1518238914
Name:KELLEY, KENNETH JAMES (OTR/L)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:KELLEY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FARMHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2170
Mailing Address - Country:US
Mailing Address - Phone:631-775-8533
Mailing Address - Fax:
Practice Address - Street 1:6 FARMHOUSE DR
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-2170
Practice Address - Country:US
Practice Address - Phone:631-775-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016948225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist