Provider Demographics
NPI:1205025665
Name:DIMOND, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:DIMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14077 DEER HAVEN CV
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5540
Mailing Address - Country:US
Mailing Address - Phone:801-815-1602
Mailing Address - Fax:
Practice Address - Street 1:1485 INTERNATIONAL PKWY
Practice Address - Street 2:2051
Practice Address - City:HEATHROW
Practice Address - State:FL
Practice Address - Zip Code:32746-5303
Practice Address - Country:US
Practice Address - Phone:800-798-6035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6240616224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant