Provider Demographics
NPI:1689828857
Name:KELLY, MARY JANE (COTA)
Entity Type:Individual
Prefix:MS
First Name:MARY JANE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6801 HIGH GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-7585
Mailing Address - Country:US
Mailing Address - Phone:630-734-4588
Mailing Address - Fax:630-920-2453
Practice Address - Street 1:6801 HIGH GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7585
Practice Address - Country:US
Practice Address - Phone:630-734-4588
Practice Address - Fax:630-920-2453
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001875224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant