Provider Demographics
NPI:1114277746
Name:MILLER, KELSEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:CRAVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:405 W JACKSON ST
Mailing Address - Street 2:PO BOX 10000
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009319225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370618939001Medicaid
IL370618939402Medicaid
813990Medicare PIN
IL370618939001Medicaid