Provider Demographics
NPI:1750026399
Name:OTTEN, KELLY NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:OTTEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4447
Mailing Address - Country:US
Mailing Address - Phone:518-926-1000
Mailing Address - Fax:518-926-2012
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4447
Practice Address - Country:US
Practice Address - Phone:518-926-1000
Practice Address - Fax:518-926-2012
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026708225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist