Provider Demographics
NPI:1710117700
Name:KELLY, STEPHANIE (PT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
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 1:11 CARNEGIE AVE
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11724-2016
Mailing Address - Country:US
Mailing Address - Phone:631-363-6012
Mailing Address - Fax:631-363-4740
Practice Address - Street 1:11 CARNEGIE AVE
Practice Address - Street 2:STREET LINE 2
Practice Address - City:COLD SPRING HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11724-2016
Practice Address - Country:US
Practice Address - Phone:631-363-6012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0121341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist