Provider Demographics
NPI:1821365198
Name:KELLY, PATRICK JOHN (DPT)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 BROADWAY RM 507
Mailing Address - Street 2:SUITE 507
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-7685
Mailing Address - Country:US
Mailing Address - Phone:212-757-3551
Mailing Address - Fax:
Practice Address - Street 1:1841 BROADWAY RM 507
Practice Address - Street 2:SUITE 507
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7685
Practice Address - Country:US
Practice Address - Phone:212-757-3551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034516-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics