Basic Information
| Provider Information | |||||||||
| NPI: | 1518907930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESIMONE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | BETTEZ | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 DUDLEY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029053236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013301428 | ||||||||
| FaxNumber: | 4016263851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 KETTLE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | EAST PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029145375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012770790 | ||||||||
| FaxNumber: | 4016263851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 001024 | RI | N | Other Service Providers | Specialist | 225100000X | 01024 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.