Provider Demographics
NPI:1477728194
Name:MANSOURI, KELLY JEAN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 REEF CT
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-7300
Mailing Address - Country:US
Mailing Address - Phone:847-459-9755
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5823
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.000587224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant