Provider Demographics
NPI:1053890301
Name:MULLEN, KELLY MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MULLEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1857
Mailing Address - Country:US
Mailing Address - Phone:860-836-7902
Mailing Address - Fax:
Practice Address - Street 1:269 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1857
Practice Address - Country:US
Practice Address - Phone:860-788-7976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist