Provider Demographics
NPI:1316590524
Name:ADCOCK, KELSEY INIES (OTD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:INIES
Last Name:ADCOCK
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:INIES
Other - Last Name:WYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD
Mailing Address - Street 1:676 W WILSON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-9070
Mailing Address - Country:US
Mailing Address - Phone:870-595-4261
Mailing Address - Fax:
Practice Address - Street 1:676 W WILSON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-9070
Practice Address - Country:US
Practice Address - Phone:870-595-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3305225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist