Provider Demographics
NPI:1174829329
Name:WILLER, KELLY LYNN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WILLER
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2472
Mailing Address - Country:US
Mailing Address - Phone:301-722-3215
Mailing Address - Fax:
Practice Address - Street 1:21585 PEABODY ST
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2955
Practice Address - Country:US
Practice Address - Phone:301-904-4820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06680225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation