Provider Demographics
NPI:1659497634
Name:ELY, KELLIE (MSPT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:ELY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 JO JO RD
Mailing Address - Street 2:
Mailing Address - City:KANE
Mailing Address - State:PA
Mailing Address - Zip Code:16735-3411
Mailing Address - Country:US
Mailing Address - Phone:814-837-9338
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH POINT DR
Practice Address - Street 2:
Practice Address - City:KANE
Practice Address - State:PA
Practice Address - Zip Code:16735-9704
Practice Address - Country:US
Practice Address - Phone:814-837-6706
Practice Address - Fax:814-837-9205
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012769L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist