Provider Demographics
NPI:1730368572
Name:O'MALLEY, KELLY A (PT)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:141 SULLY'S TRAIL
Mailing Address - Street 2:SUITE 9
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534
Mailing Address - Country:US
Mailing Address - Phone:585-387-0430
Mailing Address - Fax:585-387-0431
Practice Address - Street 1:141 SULLY'S TRAIL
Practice Address - Street 2:SUITE 9
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534
Practice Address - Country:US
Practice Address - Phone:585-387-0430
Practice Address - Fax:585-387-0431
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029803174400000X
NY029803-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB9068Medicare UPIN