Healthcare Provider Details

I. General information

NPI: 1073590212
Provider Name (Legal Business Name): MARY KELLY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY JEFFRIES PT

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3381 W MAIN ST STE 1
ST CHARLES IL
60175-1008
US

IV. Provider business mailing address

3381 W MAIN ST STE 1
ST CHARLES IL
60175-1008
US

V. Phone/Fax

Practice location:
  • Phone: 630-549-0511
  • Fax: 630-549-0512
Mailing address:
  • Phone: 630-549-0511
  • Fax: 630-549-0512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070-011761
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: