Provider Demographics
NPI:1831498856
Name:GAITHER, KELLEY MARIE
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:MARIE
Last Name:GAITHER
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 1:1874 ROBIN MILLS CT
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5816
Mailing Address - Country:US
Mailing Address - Phone:618-345-9396
Mailing Address - Fax:618-343-9392
Practice Address - Street 1:1874 ROBIN MILLS CT
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5816
Practice Address - Country:US
Practice Address - Phone:618-345-9396
Practice Address - Fax:618-343-9392
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG36051375937222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist