Provider Demographics
NPI:1740746395
Name:ELSE, KELLYANN PATRICIA (DOTR/L)
Entity type:Individual
Prefix:
First Name:KELLYANN
Middle Name:PATRICIA
Last Name:ELSE
Suffix:
Gender:F
Credentials:DOTR/L
Other - Prefix:
Other - First Name:KELLYANN
Other - Middle Name:PATRICIA
Other - Last Name:BRAMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 MARLBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 MARLBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2917
Practice Address - Country:US
Practice Address - Phone:856-472-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117875225X00000X
NJ46TR01126700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist