Provider Demographics
NPI:1598207748
Name:KELLY, BRIDGET ANN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
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 1:8912 BLAKENEY PROFESSIONAL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6735
Mailing Address - Country:US
Mailing Address - Phone:704-544-5353
Mailing Address - Fax:704-544-5382
Practice Address - Street 1:1630 101ST AVE NE
Practice Address - Street 2:SUITE 140
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-3400
Practice Address - Country:US
Practice Address - Phone:763-703-3509
Practice Address - Fax:763-703-3454
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist