Provider Demographics
NPI:1750955951
Name:BRAGGER, KELLY MARIE (LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:BRAGGER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 SEAMAN AVE APT D4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1285
Mailing Address - Country:US
Mailing Address - Phone:917-856-1438
Mailing Address - Fax:
Practice Address - Street 1:375 E MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8418
Practice Address - Country:US
Practice Address - Phone:631-343-4184
Practice Address - Fax:631-343-4168
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009649-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty