Provider Demographics
NPI:1457601098
Name:KELLY, STEPHEN PATRICK (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PATRICK
Last Name:KELLY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 WESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-5122
Mailing Address - Country:US
Mailing Address - Phone:631-979-7224
Mailing Address - Fax:631-979-7224
Practice Address - Street 1:6080 JERICHO TPKE STE 200
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2808
Practice Address - Country:US
Practice Address - Phone:631-979-7224
Practice Address - Fax:631-979-7224
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7141919172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist