Provider Demographics
NPI:1508193830
Name:NESBITT, KELLY A
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:NESBITT
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 1:11 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2503
Mailing Address - Country:US
Mailing Address - Phone:207-318-1245
Mailing Address - Fax:
Practice Address - Street 1:383 US ROUTE 1 STE 4
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9843
Practice Address - Country:US
Practice Address - Phone:207-883-1211
Practice Address - Fax:207-883-1224
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1284225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology