Provider Demographics
NPI:1518385376
Name:KELLY, ADAM RICHARD (ATC)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:RICHARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N OAK ST
Mailing Address - Street 2:APT. 4
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2661
Mailing Address - Country:US
Mailing Address - Phone:309-310-5762
Mailing Address - Fax:
Practice Address - Street 1:401 N OAK ST
Practice Address - Street 2:APT. 4
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2661
Practice Address - Country:US
Practice Address - Phone:309-310-5762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-30
Last Update Date:2014-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer