Provider Demographics
NPI:1477034239
Name:DALE, KELLY PATRICIA (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:PATRICIA
Last Name:DALE
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 1:3835 N JANSSEN AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2837
Mailing Address - Country:US
Mailing Address - Phone:630-687-0779
Mailing Address - Fax:
Practice Address - Street 1:8707 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2269
Practice Address - Country:US
Practice Address - Phone:847-877-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012625225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist