Provider Demographics
NPI:1578931291
Name:SCULLY, KELLY ANN (MS, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:SCULLY
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 W TURNER RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-0530
Mailing Address - Country:US
Mailing Address - Phone:415-794-1227
Mailing Address - Fax:
Practice Address - Street 1:413 W TURNER RD
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-0530
Practice Address - Country:US
Practice Address - Phone:415-794-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR298281225X00000X
CA13526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist