Provider Demographics
NPI:1619495751
Name:FARHAT, KELLI ANNE (OT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANNE
Last Name:FARHAT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 EASTGATE MALL
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1979
Mailing Address - Country:US
Mailing Address - Phone:858-357-9450
Mailing Address - Fax:858-412-6376
Practice Address - Street 1:5446 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3644
Practice Address - Country:US
Practice Address - Phone:719-598-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21360225X00000X, 225X00000X
3747P1801X
CO0006383225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014254700Medicaid