Provider Demographics
NPI:1881032845
Name:KELLEY, WENDY SUE
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:SUE
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 LYMAN ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-1482
Mailing Address - Country:US
Mailing Address - Phone:508-329-1171
Mailing Address - Fax:
Practice Address - Street 1:24 LYMAN ST
Practice Address - Street 2:SUITE 140
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1482
Practice Address - Country:US
Practice Address - Phone:508-329-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8276225100000X
2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics