Provider Demographics
NPI:1922705508
Name:COLEGROVE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COLEGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 452
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-0452
Mailing Address - Country:US
Mailing Address - Phone:860-829-5511
Mailing Address - Fax:
Practice Address - Street 1:1138 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2242
Practice Address - Country:US
Practice Address - Phone:860-829-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist