Healthcare Provider Details

I. General information

NPI: 1265670475
Provider Name (Legal Business Name): KELLY ELEANOR O'MARA PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3255 BRIGHTON HENRIETTA TOWN LINE RD SUITE 102
ROCHESTER NY
14623-2806
US

IV. Provider business mailing address

3255 BRIGHTON HENRIETTA TOWN LINE RD SUITE 102
ROCHESTER NY
14623-2806
US

V. Phone/Fax

Practice location:
  • Phone: 585-427-7610
  • Fax: 585-427-7410
Mailing address:
  • Phone: 585-427-7610
  • Fax: 585-427-7410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number030956
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: