Provider Demographics
NPI:1386919892
Name:KELLEY, JUSTIN ARTHUR (PTA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ARTHUR
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7264 FRIEDRICH RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-9534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7264 FRIEDRICH RD
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-9534
Practice Address - Country:US
Practice Address - Phone:989-619-6258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23204225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant