Provider Demographics
NPI:1609899103
Name:KELLY, MARIA (PT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KELLY
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 1:11122B N CEDARBURG RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-4357
Mailing Address - Country:US
Mailing Address - Phone:262-236-0176
Mailing Address - Fax:262-236-0178
Practice Address - Street 1:11122B N CEDARBURG RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-4357
Practice Address - Country:US
Practice Address - Phone:262-236-0176
Practice Address - Fax:262-236-0178
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36119100Medicaid
WI85185Medicare ID - Type Unspecified