Provider Demographics
NPI:1649736364
Name:O'LEARY, KELSEY NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MENDOTA DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-3852
Mailing Address - Country:US
Mailing Address - Phone:585-690-0098
Mailing Address - Fax:
Practice Address - Street 1:1630 E 15TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1192
Practice Address - Country:US
Practice Address - Phone:866-867-8632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY039240OtherNY PT LINENSING BOARD
MEPT5525OtherME PT LICENSING BOARD