Provider Demographics
NPI:1679665046
Name:KELLY, JANET D (OT)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:D
Last Name:KELLY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:D
Other - Last Name:BUITRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:300 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1528
Practice Address - Country:US
Practice Address - Phone:219-836-0027
Practice Address - Fax:219-836-0067
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003572225X00000X
IN31003868A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01228322OtherMEDICARE RAILROAD
INP01228322OtherMEDICARE RAILROAD
IL202845279Medicare PIN