Provider Demographics
NPI:1699722504
Name:KELLY, STEPHEN (PT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY
Mailing Address - Street 2:STE 307
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:80 MILL ST
Practice Address - Street 2:1
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1411
Practice Address - Country:US
Practice Address - Phone:973-940-7311
Practice Address - Fax:973-940-7342
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ40QA01031900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ15943Medicare ID - Type Unspecified