Provider Demographics
NPI:1699856773
Name:HAMERLA, KELLY E (OT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:HAMERLA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MAPLE STREET
Mailing Address - Street 2:PO BOX 470
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-0470
Mailing Address - Country:US
Mailing Address - Phone:715-356-8000
Mailing Address - Fax:
Practice Address - Street 1:240 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-0470
Practice Address - Country:US
Practice Address - Phone:715-356-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2812-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40804400Medicaid