Provider Demographics
NPI:1659729952
Name:KELLY, EILEEN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:KELLY
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 1:1 SKYLINE DR
Mailing Address - Street 2:SUITE 298
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2157
Mailing Address - Country:US
Mailing Address - Phone:914-347-5990
Mailing Address - Fax:914-347-5236
Practice Address - Street 1:1 SKYLINE DR
Practice Address - Street 2:SUITE 298
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2157
Practice Address - Country:US
Practice Address - Phone:914-347-5990
Practice Address - Fax:914-347-5236
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011290-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist