Provider Demographics
NPI:1629224860
Name:KELLY DREVECKY
Entity Type:Organization
Organization Name:KELLY DREVECKY
Other - Org Name:PRAIRIE THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRACTICIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LON
Authorized Official - Last Name:DREVECKY
Authorized Official - Suffix:
Authorized Official - Credentials:OT R/L
Authorized Official - Phone:1701-720-5355
Mailing Address - Street 1:700 HARMONY ST NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2892
Mailing Address - Country:US
Mailing Address - Phone:701-720-5355
Mailing Address - Fax:701-839-1311
Practice Address - Street 1:700 HARMONY ST NW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2892
Practice Address - Country:US
Practice Address - Phone:701-720-5355
Practice Address - Fax:701-839-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND612225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1023153921OtherALLI HAGER'S NPI
ND50609Medicaid
1457303695OtherNPI FOR KELLY DREVECKY
ND51145Medicaid
ND51500Medicaid
711934Medicare UPIN