Provider Demographics
NPI:1891061719
Name:BAGDASSIAN, KELLY A
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:BAGDASSIAN
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 1:1302 MELVIN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4150
Mailing Address - Country:US
Mailing Address - Phone:262-412-8320
Mailing Address - Fax:
Practice Address - Street 1:1302 MELVIN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4150
Practice Address - Country:US
Practice Address - Phone:262-412-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-25
Last Update Date:2012-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.006671225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist