Provider Demographics
NPI:1811261134
Name:KELLY, KATHRYN (MSPT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-4317
Mailing Address - Country:US
Mailing Address - Phone:571-278-4320
Mailing Address - Fax:
Practice Address - Street 1:17 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-4317
Practice Address - Country:US
Practice Address - Phone:571-278-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI02982225100000X
VA2305204799225100000X
PA025270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist