MEDICARE: MAUREEN ELIZABETH KELLY P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2247	OR

General Provider Information

NPI Number	:	1578549671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAUREEN ELIZABETH KELLY P.T.

Provider Business Mailing Address
First Line	:	8317 N HARTMAN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-1103
Country	:	US
Telephone Number	:	541-510-9612
Fax Number	:

Provider Business Practice Location Address
First Line	:	8317 N HARTMAN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-1103
Country	:	US
Telephone Number	:	541-510-9612
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	07/27/2011

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