Provider Demographics
NPI:1558844928
Name:KELLAMS, KATELYN MARIE (OTR)
Entity Type:Individual
Prefix:MISS
First Name:KATELYN
Middle Name:MARIE
Last Name:KELLAMS
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 1:114 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-1620
Mailing Address - Country:US
Mailing Address - Phone:573-450-7280
Mailing Address - Fax:
Practice Address - Street 1:8745 JAMES A REED RD
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138-4414
Practice Address - Country:US
Practice Address - Phone:816-761-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
404281225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018026320OtherSTATE LICENSED OCCUPATIONAL THERAPIST
404281OtherOCCUPATIONAL THERAPIST REGISTERED