Healthcare Provider Details

I. General information

NPI: 1659348035
Provider Name (Legal Business Name): ANNE GERISE KELLY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNE GERISE HEITZMAN PT

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 WEST AFTON AVE SUITE G 5 AND 6
YARDLEY PA
19067
US

IV. Provider business mailing address

8 GRENLOCH DR
TITUSVILLE NJ
08560-1114
US

V. Phone/Fax

Practice location:
  • Phone: 215-493-2666
  • Fax: 215-493-6639
Mailing address:
  • Phone: 609-466-2071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016085
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier001682843
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUESHIELD
# 2
Identifier2356289000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerIBC
# 3
Identifier1011197760001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: