Provider Demographics
NPI:1083138689
Name:MAKI, KELLY (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAKI
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10631 S 51ST ST STE 8
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5225
Mailing Address - Country:US
Mailing Address - Phone:480-398-4280
Mailing Address - Fax:480-398-4281
Practice Address - Street 1:2150 S COUNTRY CLUB DR STE 20
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6879
Practice Address - Country:US
Practice Address - Phone:480-398-4280
Practice Address - Fax:480-398-4281
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7085225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist