Healthcare Provider Details

I. General information

NPI: 1790162964
Provider Name (Legal Business Name): KAYLEE KELLEY PT, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 BARRA RD
BIDDEFORD ME
04005-9459
US

IV. Provider business mailing address

12 OAKMONT DR
OLD ORCHARD BEACH ME
04064-4138
US

V. Phone/Fax

Practice location:
  • Phone: 207-283-7226
  • Fax:
Mailing address:
  • Phone: 207-423-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPT3936
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3936
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0
Identifier TypeOTHER
Identifier StateME
Identifier Issuer0

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: