Provider Demographics
NPI:1306285564
Name:KELLY, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:3218 DAUGHERTY DR
Practice Address - Street 2:SUITE 160
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-3997
Practice Address - Country:US
Practice Address - Phone:765-477-6464
Practice Address - Fax:765-477-6262
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011222A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist