Provider Demographics
NPI:1336627793
Name:MACIEUNAS, KELLY ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MACIEUNAS
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 1:27 E LAKEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18214-2032
Mailing Address - Country:US
Mailing Address - Phone:570-467-0460
Mailing Address - Fax:
Practice Address - Street 1:149 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-4619
Practice Address - Country:US
Practice Address - Phone:570-668-0337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-29
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003676L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist