Provider Demographics
NPI:1851547582
Name:DEWEESE, KELLY ERIN (MOT, ORT/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ERIN
Last Name:DEWEESE
Suffix:
Gender:F
Credentials:MOT, ORT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WEST 94TH STREET
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420
Mailing Address - Country:US
Mailing Address - Phone:952-885-0418
Mailing Address - Fax:952-885-0173
Practice Address - Street 1:900 WEST 94TH STREET
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420
Practice Address - Country:US
Practice Address - Phone:952-885-0418
Practice Address - Fax:952-885-0173
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103602225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist