Provider Demographics
NPI:1336867183
Name:KELLY, TREVOR (DPT)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 MAIN ST
Mailing Address - Street 2:STE 103
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472
Mailing Address - Country:US
Mailing Address - Phone:617-924-5100
Mailing Address - Fax:617-924-5199
Practice Address - Street 1:85 MAIN ST
Practice Address - Street 2:STE 103
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472
Practice Address - Country:US
Practice Address - Phone:617-924-5100
Practice Address - Fax:617-924-5199
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist