Healthcare Provider Details

I. General information

NPI: 1134760440
Provider Name (Legal Business Name): DEVIN KELLY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 DALE RD STE 203
AVON CT
06001-4351
US

IV. Provider business mailing address

47 N MAIN ST
WEST HARTFORD CT
06107-1926
US

V. Phone/Fax

Practice location:
  • Phone: 860-674-1713
  • Fax:
Mailing address:
  • Phone: 860-409-4595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14732
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9662
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: