Provider Demographics
NPI:1346428414
Name:KELLY, KIMI MARIE (OT)
Entity Type:Individual
Prefix:
First Name:KIMI
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KIMI
Other - Middle Name:MARIE
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:2757 NICOLET DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-7219
Mailing Address - Country:US
Mailing Address - Phone:920-391-1565
Mailing Address - Fax:
Practice Address - Street 1:2661 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5305
Practice Address - Country:US
Practice Address - Phone:920-592-5262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI383026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist