Provider Demographics
NPI:1952682155
Name:WELLS, KENYA NICOLE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KENYA
Middle Name:NICOLE
Last Name:WELLS
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 1:6204 POND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2479
Mailing Address - Country:US
Mailing Address - Phone:773-617-0478
Mailing Address - Fax:
Practice Address - Street 1:6204 POND VIEW DR
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2479
Practice Address - Country:US
Practice Address - Phone:773-617-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.005572225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist