Provider Demographics
NPI:1821332305
Name:KING, KELLY ANN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:KING
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 1:15930 CARVER HIGHLANDS DR
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MN
Mailing Address - Zip Code:55315-9657
Mailing Address - Country:US
Mailing Address - Phone:612-770-0243
Mailing Address - Fax:
Practice Address - Street 1:622 ABERDEEN AVE
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-9516
Practice Address - Country:US
Practice Address - Phone:952-492-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103544225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist