Provider Demographics
NPI:1356685440
Name:LYNCH, KELLY MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:LYNCH
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 1:5123 N NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-3716
Mailing Address - Country:US
Mailing Address - Phone:773-419-7803
Mailing Address - Fax:
Practice Address - Street 1:600 N BRADLEY RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1020
Practice Address - Country:US
Practice Address - Phone:847-615-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009906225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist