Provider Demographics
NPI:1073147096
Name:DEMILLE, KELLEA (MSC)
Entity Type:Individual
Prefix:
First Name:KELLEA
Middle Name:
Last Name:DEMILLE
Suffix:
Gender:F
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9603 AUTUMNWOOD PL
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-5776
Mailing Address - Country:US
Mailing Address - Phone:512-705-1259
Mailing Address - Fax:
Practice Address - Street 1:2100 E MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-1342
Practice Address - Country:US
Practice Address - Phone:512-900-7934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
CO0008240225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000Medicaid