Provider Demographics
NPI:1467682070
Name:PETERSON, KELLY RENEE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:PETERSON
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 1:1200 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARITON
Mailing Address - State:IA
Mailing Address - Zip Code:50049-1210
Mailing Address - Country:US
Mailing Address - Phone:641-774-3000
Mailing Address - Fax:641-774-3207
Practice Address - Street 1:1200 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARITON
Practice Address - State:IA
Practice Address - Zip Code:50049-1210
Practice Address - Country:US
Practice Address - Phone:641-774-3000
Practice Address - Fax:641-774-3207
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01298225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist