Provider Demographics
NPI:1679901458
Name:KELLY, MARY LEE
Entity type:Individual
Prefix:
First Name:MARY LEE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5705
Mailing Address - Country:US
Mailing Address - Phone:304-242-1390
Mailing Address - Fax:304-243-5880
Practice Address - Street 1:1305 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5705
Practice Address - Country:US
Practice Address - Phone:304-242-1390
Practice Address - Fax:304-243-5880
Is Sole Proprietor?:No
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV736225XP0200X
OH004260225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics