Provider Demographics
NPI:1518580091
Name:O'TOOLE, KELLI J
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:O'TOOLE
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 1:701 3RD ST NW
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-2963
Mailing Address - Country:US
Mailing Address - Phone:800-568-5175
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN AVE
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6811
Practice Address - Country:US
Practice Address - Phone:701-429-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician