Provider Demographics
NPI:1700963477
Name:DERUVO, KELLY (DPT)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:
Last Name:DERUVO
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 1:17 PARSONS WAY
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NH
Mailing Address - Zip Code:03848-3657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NH
Practice Address - Zip Code:03848-3222
Practice Address - Country:US
Practice Address - Phone:516-594-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223120225100000X
NY026447-1225100000X
NH4194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ008H1Medicare PIN