Provider Demographics
NPI:1467054551
Name:LOOMIS, KELLY ANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:LOOMIS
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 1:4650 EDENVALE AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-5509
Mailing Address - Country:US
Mailing Address - Phone:714-932-9009
Mailing Address - Fax:
Practice Address - Street 1:4650 EDENVALE AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5509
Practice Address - Country:US
Practice Address - Phone:714-932-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9069225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist