Provider Demographics
NPI:1396776290
Name:KELLY, ELLEN BETH (ATC)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:BETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5703 NEWNAN CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-3197
Mailing Address - Country:US
Mailing Address - Phone:404-273-5012
Mailing Address - Fax:
Practice Address - Street 1:5040 SNAPFINGER WOODS DR
Practice Address - Street 2:SUITE 205
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-4020
Practice Address - Country:US
Practice Address - Phone:678-205-5736
Practice Address - Fax:678-205-5739
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0010022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer