Provider Demographics
NPI:1396226346
Name:MCCORMICK, KELLEY ANNE (OTR)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANNE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12042 BITTERN HOLW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-3350
Mailing Address - Country:US
Mailing Address - Phone:512-730-2124
Mailing Address - Fax:
Practice Address - Street 1:12042 BITTERN HOLW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-3350
Practice Address - Country:US
Practice Address - Phone:512-730-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118446225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist