Provider Demographics
NPI:1790162964
Name:KELLEY, KAYLEE (PT, CLT)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 OAKMONT DR
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-4138
Mailing Address - Country:US
Mailing Address - Phone:207-423-7715
Mailing Address - Fax:
Practice Address - Street 1:46 BARRA RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9459
Practice Address - Country:US
Practice Address - Phone:207-283-7226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3936314000000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0Other0