Provider Demographics
NPI:1972024909
Name:KELLY, KATIE (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-8815
Mailing Address - Country:US
Mailing Address - Phone:845-796-1350
Mailing Address - Fax:845-791-8073
Practice Address - Street 1:162 E BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701
Practice Address - Country:US
Practice Address - Phone:845-796-1350
Practice Address - Fax:845-791-8073
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021564225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist