Provider Demographics
NPI:1326590662
Name:WHITT, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHITT
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 1:28515 N NORTH VALLEY PKWY
Mailing Address - Street 2:APT 1096
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5401
Mailing Address - Country:US
Mailing Address - Phone:623-313-3469
Mailing Address - Fax:
Practice Address - Street 1:28515 N NORTH VALLEY PKWY
Practice Address - Street 2:APT 1096
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-5401
Practice Address - Country:US
Practice Address - Phone:623-313-3469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6709224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant