Provider Demographics
NPI:1184673493
Name:LEWIS, KELLEY D (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:D
Last Name:LEWIS
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 1:130 UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:BEEBE
Mailing Address - State:AR
Mailing Address - Zip Code:72012-9751
Mailing Address - Country:US
Mailing Address - Phone:501-230-3100
Mailing Address - Fax:501-882-9825
Practice Address - Street 1:130 UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:BEEBE
Practice Address - State:AR
Practice Address - Zip Code:72012-9751
Practice Address - Country:US
Practice Address - Phone:501-230-3100
Practice Address - Fax:501-882-9825
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 942171W00000X
AROTR1999225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143895721Medicaid