Provider Demographics
NPI:1891041174
Name:BUBB-KELLY, KATRINA R (PT)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:R
Last Name:BUBB-KELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LYONS ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-5599
Mailing Address - Country:US
Mailing Address - Phone:781-329-1400
Mailing Address - Fax:781-329-0078
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:781-329-1400
Practice Address - Fax:781-329-0078
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist