Provider Demographics
NPI:1851568034
Name:BASHAM, KELLEY (OTA)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BASHAM
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2123
Mailing Address - Country:US
Mailing Address - Phone:502-568-1000
Mailing Address - Fax:502-568-1015
Practice Address - Street 1:825 S 6TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2123
Practice Address - Country:US
Practice Address - Phone:502-568-1000
Practice Address - Fax:502-568-1015
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA2664224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant