Provider Demographics
NPI:1710138177
Name:KELLY, MELISSA JAY (PTA)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:JAY
Last Name:KELLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 E ARLINGTON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-7850
Mailing Address - Country:US
Mailing Address - Phone:252-758-7048
Mailing Address - Fax:252-215-5614
Practice Address - Street 1:1330 E ARLINGTON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-7850
Practice Address - Country:US
Practice Address - Phone:252-758-7048
Practice Address - Fax:252-215-5614
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC979225200000X
NC1575225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist