Provider Demographics
NPI:1679238083
Name:RANDALL, KELLY (OTD/OTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:OTD/OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416501
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7594
Mailing Address - Country:US
Mailing Address - Phone:194-294-4050
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:1442 OLD SKOKIE VALLEY RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3032
Practice Address - Country:US
Practice Address - Phone:847-748-8870
Practice Address - Fax:847-786-2156
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist