Provider Demographics
NPI:1558574459
Name:DELONG, KELLY MAUREEN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MAUREEN
Last Name:DELONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MAUREEN
Other - Last Name:MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:25815 N 41ST WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-9006
Mailing Address - Country:US
Mailing Address - Phone:480-678-2687
Mailing Address - Fax:480-656-4853
Practice Address - Street 1:25815 N 41ST WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-9006
Practice Address - Country:US
Practice Address - Phone:480-678-2687
Practice Address - Fax:480-656-4853
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist