Provider Demographics
NPI:1174817043
Name:MATUTINA, KELLY GROTE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GROTE
Last Name:MATUTINA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5668 MEADOWCREST ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4816
Mailing Address - Country:US
Mailing Address - Phone:928-234-8429
Mailing Address - Fax:
Practice Address - Street 1:650 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-1427
Practice Address - Country:US
Practice Address - Phone:540-345-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119002058225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist