Provider Demographics
NPI:1265942809
Name:KELLY, KRISTEN D (OTR/L)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:D
Last Name:KELLY
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 1:207 DUDLEY PIKE
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2674
Mailing Address - Country:US
Mailing Address - Phone:859-743-6133
Mailing Address - Fax:
Practice Address - Street 1:2865 CHANCELLOR DR STE 105
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3913
Practice Address - Country:US
Practice Address - Phone:859-426-5666
Practice Address - Fax:859-426-5665
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY132739225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist