Provider Demographics
NPI:1356970412
Name:KELLY, CHANDLER T (OTR, OTD)
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:T
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR, OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11751 ALTA VISTA RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6442
Mailing Address - Country:US
Mailing Address - Phone:817-562-1006
Mailing Address - Fax:817-562-1009
Practice Address - Street 1:11751 ALTA VISTA RD STE 201
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6442
Practice Address - Country:US
Practice Address - Phone:817-562-1006
Practice Address - Fax:817-562-1009
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-114824106S00000X
TX125011225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
517461OtherOT NATIONAL LICENSE ISSUED BY NBCOT
TX125011OtherOCCUPATIONAL THERAPY TEXAS STATE LICENSE