Provider Demographics
NPI:1619611571
Name:KELLY, TEARA MICHELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TEARA
Middle Name:MICHELLE
Last Name:KELLY
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 1:142 BIRCHWOOD DR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-3038
Mailing Address - Country:US
Mailing Address - Phone:737-738-4124
Mailing Address - Fax:
Practice Address - Street 1:2011 BROADWAY ST STE 130
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5945
Practice Address - Country:US
Practice Address - Phone:281-997-8509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist