Provider Demographics
NPI:1255900353
Name:MATTHEWS, KELLY (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MATTHEWS
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 1:22 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-9682
Mailing Address - Country:US
Mailing Address - Phone:518-281-2070
Mailing Address - Fax:
Practice Address - Street 1:85 BLOOMINGROVE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8433
Practice Address - Country:US
Practice Address - Phone:518-283-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017437-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist