Provider Demographics
NPI:1083157218
Name:EDER, KELLI CLAUDETTE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:CLAUDETTE
Last Name:EDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 CHAMPIONS TRACE LN STE 102
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3496
Mailing Address - Country:US
Mailing Address - Phone:502-736-3051
Mailing Address - Fax:
Practice Address - Street 1:4710 CHAMPIONS TRACE LN STE 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3496
Practice Address - Country:US
Practice Address - Phone:502-736-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-20
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170844221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist