Provider Demographics
NPI:1578289153
Name:FEDOR, KELSEY RENE (OTR/L)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:RENE
Last Name:FEDOR
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-0405
Mailing Address - Country:US
Mailing Address - Phone:779-435-0724
Mailing Address - Fax:
Practice Address - Street 1:1621 ANDREA DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2303
Practice Address - Country:US
Practice Address - Phone:779-435-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.015016225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist