Provider Demographics
NPI:1235647215
Name:WEYNAND, KELLY LAWLER (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LAWLER
Last Name:WEYNAND
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 1:9611 BROOKDALE DR STE 100-122
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8719
Mailing Address - Country:US
Mailing Address - Phone:704-807-5699
Mailing Address - Fax:
Practice Address - Street 1:1016 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4520
Practice Address - Country:US
Practice Address - Phone:704-807-5699
Practice Address - Fax:704-807-5699
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11333225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC000034225830OtherDRIVERS LICENSE