Provider Demographics
NPI:1477070118
Name:TUCKER, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SUPERIOR ST NE
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44613-1136
Mailing Address - Country:US
Mailing Address - Phone:330-437-7847
Mailing Address - Fax:
Practice Address - Street 1:2100 38TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2312
Practice Address - Country:US
Practice Address - Phone:330-492-8136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA006820224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOTA006820OtherLICENSE-COTA