Provider Demographics
NPI:1710150396
Name:BOWER, KELSEY (OTA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BOWER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3741 ROME DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4490
Mailing Address - Country:US
Mailing Address - Phone:765-250-3662
Mailing Address - Fax:
Practice Address - Street 1:3741 ROME DR STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4490
Practice Address - Country:US
Practice Address - Phone:765-250-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99030729A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA