Provider Demographics
NPI:1518440304
Name:KELLEY, ROSELLE DIZON (PT)
Entity Type:Individual
Prefix:
First Name:ROSELLE
Middle Name:DIZON
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 S WHITE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2079
Mailing Address - Country:US
Mailing Address - Phone:408-274-0888
Mailing Address - Fax:408-274-2858
Practice Address - Street 1:2680 S WHITE RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2079
Practice Address - Country:US
Practice Address - Phone:408-274-0888
Practice Address - Fax:408-274-2858
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist