Provider Demographics
NPI:1164886875
Name:KELLEY, SUSAN WALSH (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:WALSH
Last Name:KELLEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3901
Mailing Address - Country:US
Mailing Address - Phone:207-332-6547
Mailing Address - Fax:
Practice Address - Street 1:174 S FREEPORT RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6145
Practice Address - Country:US
Practice Address - Phone:855-239-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT424225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist