Provider Demographics
NPI:1578528741
Name:KELLY, CONNIE L (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 NEW RD
Mailing Address - Street 2:
Mailing Address - City:LINDWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1251
Mailing Address - Country:US
Mailing Address - Phone:609-926-1161
Mailing Address - Fax:609-926-3223
Practice Address - Street 1:601 NEW RD
Practice Address - Street 2:
Practice Address - City:LINDWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1251
Practice Address - Country:US
Practice Address - Phone:609-926-1161
Practice Address - Fax:601-926-1161
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB001210002251S0007X, 2251X0800X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant