Healthcare Provider Details

I. General information

NPI: 1710978580
Provider Name (Legal Business Name): KELLY DYKE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 JEAN AVE STE 10
CHELMSFORD MA
01824-1740
US

IV. Provider business mailing address

885 MAIN ST STE 4
TEWKSBURY MA
01876-1800
US

V. Phone/Fax

Practice location:
  • Phone: 978-441-9452
  • Fax: 978-454-9292
Mailing address:
  • Phone: 978-851-8768
  • Fax: 978-851-8606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17044
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: