Provider Demographics
NPI:1578793014
Name:CARTER, KELSEY KAY (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:KAY
Last Name:CARTER
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:KAY
Other - Last Name:LUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, OTR/L
Mailing Address - Street 1:2625 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0574
Mailing Address - Country:US
Mailing Address - Phone:701-232-3175
Mailing Address - Fax:701-222-3186
Practice Address - Street 1:601 18TH AVE SE
Practice Address - Street 2:#201
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6732
Practice Address - Country:US
Practice Address - Phone:701-852-4406
Practice Address - Fax:701-838-2572
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201570225XP0200X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN201570OtherTEMPORARY LICENSE FROM STATE OF MN