Basic Information
| Provider Information | |||||||||
| NPI: | 1942807896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | M.L | ||||||||
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| Credential: | DPT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD STE PROEX | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 CUMMINGS CTR STE 130S | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785247827 | ||||||||
| FaxNumber: | 9785247828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2020 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 25089 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.