Provider Demographics
NPI:1407327968
Name:OTIS, KELLY (RPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WHISPERING PINES DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4792
Mailing Address - Country:US
Mailing Address - Phone:831-440-8304
Mailing Address - Fax:
Practice Address - Street 1:108 WHISPERING PINES DR STE 120
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4792
Practice Address - Country:US
Practice Address - Phone:831-440-8304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT1778208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty