Provider Demographics
NPI:1457134223
Name:KELLEY, RYAN THOMAS
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:THOMAS
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 NEWTON RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-2440
Mailing Address - Country:US
Mailing Address - Phone:978-388-7272
Mailing Address - Fax:978-388-7373
Practice Address - Street 1:331 VERANDA ST STE 401
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5545
Practice Address - Country:US
Practice Address - Phone:207-536-0702
Practice Address - Fax:207-536-0785
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist