Provider Demographics
NPI:1407207335
Name:WALL, KILEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:WALL
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:PO BOX 5285
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5285
Mailing Address - Country:US
Mailing Address - Phone:308-382-0344
Mailing Address - Fax:308-382-3241
Practice Address - Street 1:3219 CENTRAL AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2949
Practice Address - Country:US
Practice Address - Phone:308-865-7182
Practice Address - Fax:308-865-2881
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1496225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist