Provider Demographics
NPI:1457551285
Name:RANDALL, KELLY ROSS (MS,OTR/L, CLT)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:ROSS
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MS,OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 EAGLE RUN
Mailing Address - Street 2:
Mailing Address - City:DELL RAPIDS
Mailing Address - State:SD
Mailing Address - Zip Code:57022-2142
Mailing Address - Country:US
Mailing Address - Phone:605-428-5851
Mailing Address - Fax:
Practice Address - Street 1:324 1ST AVE N
Practice Address - Street 2:
Practice Address - City:GEORGE
Practice Address - State:IA
Practice Address - Zip Code:51237-1029
Practice Address - Country:US
Practice Address - Phone:712-475-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01563225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist