Provider Demographics
NPI:1457402729
Name:KEHOE, ELLIS A (OT)
Entity Type:Individual
Prefix:MS
First Name:ELLIS
Middle Name:A
Last Name:KEHOE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 BEAUMONT DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-9786
Mailing Address - Country:US
Mailing Address - Phone:919-968-3456
Mailing Address - Fax:919-932-3456
Practice Address - Street 1:1829 E FRANKLIN ST
Practice Address - Street 2:BLDG. # 600
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-5861
Practice Address - Country:US
Practice Address - Phone:919-968-3456
Practice Address - Fax:919-932-3456
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
NC0211225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1189NOtherBLUE CROSS
NC7301285Medicaid