Provider Demographics
NPI:1790007888
Name:DUTTON, KELLY MARIE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:DUTTON
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 1:18564 US ROUTE 11
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5900
Mailing Address - Country:US
Mailing Address - Phone:315-786-7202
Mailing Address - Fax:
Practice Address - Street 1:18564 US ROUTE 11
Practice Address - Street 2:SUITE 5
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5900
Practice Address - Country:US
Practice Address - Phone:315-786-7202
Practice Address - Fax:315-786-1524
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012015-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist