Provider Demographics
NPI:1205354560
Name:CARRICO, KELSEY ALEXANDRA (OTR)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ALEXANDRA
Last Name:CARRICO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ALEXANDRA
Other - Last Name:KOLTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:122 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3751
Mailing Address - Country:US
Mailing Address - Phone:270-926-2122
Mailing Address - Fax:270-926-2215
Practice Address - Street 1:122 E 18TH ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3751
Practice Address - Country:US
Practice Address - Phone:270-926-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171101225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist