Provider Demographics
NPI:1194817643
Name:MARTIN, KELLEY (OTRL)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 TATE BLVD SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602
Mailing Address - Country:US
Mailing Address - Phone:283-580-9768
Mailing Address - Fax:866-750-0856
Practice Address - Street 1:1849 TATE BLVD SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602
Practice Address - Country:US
Practice Address - Phone:283-580-9768
Practice Address - Fax:866-750-0856
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT4969225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7255198Medicaid
OH366504Medicare ID - Type UnspecifiedTHE CHILDREN'S DEV. CNTR.