Provider Demographics
NPI:1548737091
Name:KELLY, JUSTIN T (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:T
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 S LOCUST ST STE 5
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5789
Mailing Address - Country:US
Mailing Address - Phone:575-521-4188
Mailing Address - Fax:575-521-3668
Practice Address - Street 1:2404 S LOCUST ST STE 5
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5789
Practice Address - Country:US
Practice Address - Phone:575-521-4188
Practice Address - Fax:575-521-3668
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-16
Deactivation Date:2018-11-01
Deactivation Code:
Reactivation Date:2018-11-16
Provider Licenses
StateLicense IDTaxonomies
NMPT5375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist