=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811261134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN KELLY MSPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2012
-----------------------------------------------------
Last Update Date | 05/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 RIVERSIDE DR
-----------------------------------------------------
City | TIVERTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02878-4317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-278-4320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 RIVERSIDE DR
-----------------------------------------------------
City | TIVERTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02878-4317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-278-4320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 02982
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2305204799
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 025270
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------