Provider Demographics
NPI:1659847911
Name:FREDERICK, KELSEY (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:FREDERICK
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 1:1718 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062-9784
Mailing Address - Country:US
Mailing Address - Phone:610-366-0500
Mailing Address - Fax:
Practice Address - Street 1:1718 SPRING CREEK RD
Practice Address - Street 2:
Practice Address - City:MACUNGIE
Practice Address - State:PA
Practice Address - Zip Code:18062-9784
Practice Address - Country:US
Practice Address - Phone:610-366-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120490225X00000X
TN6358225X00000X
PAOC015422225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist