Provider Demographics
NPI:1356544050
Name:FREY, KELLI SUSAN (OTR)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:SUSAN
Last Name:FREY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 W 113TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2751
Mailing Address - Country:US
Mailing Address - Phone:913-638-8512
Mailing Address - Fax:
Practice Address - Street 1:11501 W 113TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2751
Practice Address - Country:US
Practice Address - Phone:913-638-8512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002354171W00000X
KS17-00806171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17-00806OtherO.T. STATE LICENSE
MO002354OtherO.T. STATE LICENSE