Provider Demographics
NPI:1437726312
Name:STANDORF, KELLI (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:STANDORF
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:329 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:MINERAL POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53565-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S MADISON ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2167
Practice Address - Country:US
Practice Address - Phone:608-723-4143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6994-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist