Provider Demographics
NPI:1639311863
Name:LEYSTRA, KELLYN E (OTR)
Entity Type:Individual
Prefix:MISS
First Name:KELLYN
Middle Name:E
Last Name:LEYSTRA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541PLOVER ROAD
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-2155
Mailing Address - Country:US
Mailing Address - Phone:715-423-5423
Mailing Address - Fax:715-423-1532
Practice Address - Street 1:3541PLOVER ROAD
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-2155
Practice Address - Country:US
Practice Address - Phone:715-423-5423
Practice Address - Fax:715-423-1532
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4735-026225X00000X
WI4735-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist