Provider Demographics
NPI:1710186689
Name:BARTLEY, KELLY BROOK (MPT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:BROOK
Last Name:BARTLEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RTE 51 BOX 81
Mailing Address - Street 2:
Mailing Address - City:HANNACROIX
Mailing Address - State:NY
Mailing Address - Zip Code:12087
Mailing Address - Country:US
Mailing Address - Phone:518-475-8524
Mailing Address - Fax:
Practice Address - Street 1:3358 DALEY CENTER DR APT 1413
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4629
Practice Address - Country:US
Practice Address - Phone:518-221-9976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist