Provider Demographics
NPI:1780814905
Name:BECKER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 PROBASCO ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-2710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 PROBASCO ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2710
Practice Address - Country:US
Practice Address - Phone:513-281-2464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH100013224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant