Provider Demographics
NPI:1639258460
Name:LOCKE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LOCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRYEBURG
Mailing Address - State:ME
Mailing Address - Zip Code:04037-1146
Mailing Address - Country:US
Mailing Address - Phone:207-935-7770
Mailing Address - Fax:207-935-7773
Practice Address - Street 1:37 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6166
Practice Address - Country:US
Practice Address - Phone:603-447-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE5083Medicare ID - Type Unspecified