Basic Information
| Provider Information | |||||||||
| NPI: | 1235408568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY-GALLELLO | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | CARLA | ||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | GALLELLO | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | CARLA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11 EAGLE ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | EAST HANOVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079363167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738879000 | ||||||||
| FaxNumber: | 9738873816 | ||||||||
| Practice Location | |||||||||
| Address1: | 1161 BURNT TAVERN RD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324581755 | ||||||||
| FaxNumber: | 7324586408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2011 | ||||||||
| LastUpdateDate: | 05/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01428300 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.