Provider Demographics
NPI:1285718601
Name:KELLY, SUZAN J (PT, LAC)
Entity type:Individual
Prefix:
First Name:SUZAN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26621 CARMEL CENTER PL
Mailing Address - Street 2:SUITE #201
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-8657
Mailing Address - Country:US
Mailing Address - Phone:831-626-0540
Mailing Address - Fax:831-622-7463
Practice Address - Street 1:26621 CARMEL CENTER PL
Practice Address - Street 2:SUITE #201
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923-8657
Practice Address - Country:US
Practice Address - Phone:831-626-0540
Practice Address - Fax:831-622-7463
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACL2500171100000X
CAPT8937225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT89370Medicare ID - Type UnspecifiedPHYSICAL THERAPY