Provider Demographics
NPI:1821438516
Name:REARDON, KELLY ANN (MOTR/L)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:REARDON
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:1216 W 69TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64113-2055
Mailing Address - Country:US
Mailing Address - Phone:913-515-3531
Mailing Address - Fax:816-222-0679
Practice Address - Street 1:3715 W 133RD ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209-3347
Practice Address - Country:US
Practice Address - Phone:913-515-3531
Practice Address - Fax:816-222-0679
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-02875225X00000X
MO2011024109225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist