Provider Demographics
NPI:1023228913
Name:KELLY, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 THERESA ST
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-1239
Mailing Address - Country:US
Mailing Address - Phone:413-297-2414
Mailing Address - Fax:
Practice Address - Street 1:349 BIDWELL ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6471
Practice Address - Country:US
Practice Address - Phone:860-647-9191
Practice Address - Fax:860-643-6147
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000275225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant