Provider Demographics
NPI:1346790680
Name:LANGE, KELLIE AYN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:AYN
Last Name:LANGE
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 1:5012 E MANSLICK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-5165
Mailing Address - Country:US
Mailing Address - Phone:502-969-3277
Mailing Address - Fax:502-969-3259
Practice Address - Street 1:5012 E MANSLICK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-5165
Practice Address - Country:US
Practice Address - Phone:502-969-3277
Practice Address - Fax:502-969-3259
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY131965225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist