Provider Demographics
NPI:1508007709
Name:VILLEGAS, KELLEY ELISE (OTR)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ELISE
Last Name:VILLEGAS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 PRIMERA BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2168
Mailing Address - Country:US
Mailing Address - Phone:407-362-1902
Mailing Address - Fax:407-804-9769
Practice Address - Street 1:255 PRIMERA BLVD STE 160
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2168
Practice Address - Country:US
Practice Address - Phone:407-362-1902
Practice Address - Fax:407-804-9769
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104819225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202949801Medicaid