Provider Demographics
NPI:1205460219
Name:KELLISH, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:KELLISH
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 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-359-5859
Mailing Address - Fax:631-396-0864
Practice Address - Street 1:105 ELM ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-3143
Practice Address - Country:US
Practice Address - Phone:908-264-7503
Practice Address - Fax:908-264-7596
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01916600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist