Provider Demographics
NPI:1316154057
Name:TRUSSELL, KELLY RENEE (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 COLUMBUS AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5153
Mailing Address - Country:US
Mailing Address - Phone:757-329-8853
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-9226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist