Provider Demographics
NPI:1346659604
Name:KELLEY, COLLEEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:KELLEY
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 1:218 REDONDO AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5903
Mailing Address - Country:US
Mailing Address - Phone:401-787-5878
Mailing Address - Fax:
Practice Address - Street 1:218 REDONDO AVE APT 7
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-5903
Practice Address - Country:US
Practice Address - Phone:401-787-5878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14470225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist