Provider Demographics
NPI:1841263472
Name:FABIAN, KELLY (PT, ATC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FABIAN
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2173
Mailing Address - Country:US
Mailing Address - Phone:856-802-1218
Mailing Address - Fax:
Practice Address - Street 1:3001 BRIDGEBORO RD
Practice Address - Street 2:
Practice Address - City:DELRAN
Practice Address - State:NJ
Practice Address - Zip Code:08075-9700
Practice Address - Country:US
Practice Address - Phone:856-764-0494
Practice Address - Fax:856-764-0580
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00922100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ044757Medicare ID - Type Unspecified