Provider Demographics
NPI:1356888572
Name:BOWER, KELLY (OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOWER
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 1:9813 CHESTNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14105-9680
Mailing Address - Country:US
Mailing Address - Phone:716-474-0890
Mailing Address - Fax:
Practice Address - Street 1:9813 CHESTNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:MIDDLEPORT
Practice Address - State:NY
Practice Address - Zip Code:14105-9680
Practice Address - Country:US
Practice Address - Phone:716-474-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63 020830225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist