Provider Demographics
NPI:1457303695
Name:DREVECKY, KELLY LON (OT R/L)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:LON
Last Name:DREVECKY
Suffix:
Gender:M
Credentials:OT R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 HARMONY ST NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2892
Mailing Address - Country:US
Mailing Address - Phone:701-720-5355
Mailing Address - Fax:701-839-1311
Practice Address - Street 1:700 HARMONY ST NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2892
Practice Address - Country:US
Practice Address - Phone:701-720-5355
Practice Address - Fax:701-839-1311
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND612225X00000X, 225XN1300X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND50609Medicaid
711934Medicare PIN