Provider Demographics
NPI:1942550405
Name:BLACK, KELLY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 PARKERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-5892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4101 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4114
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009759225X00000X
NC11328225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist