Provider Demographics
NPI:1265523500
Name:KELLY, THOMAS J (PT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2225 DELTA WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-9108
Mailing Address - Country:US
Mailing Address - Phone:865-687-4537
Mailing Address - Fax:865-687-5367
Practice Address - Street 1:2704 MINERAL SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-1562
Practice Address - Country:US
Practice Address - Phone:865-687-4537
Practice Address - Fax:865-687-5367
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3123654OtherBCBSTN
TN0446566Medicaid
TN3123654OtherBCBSTN