Provider Demographics
NPI:1780741579
Name:CHRISTIANSEN, KELLY MARIE (OTRL)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:CHRISTIANSEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 CRANE PT
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-7885
Mailing Address - Country:US
Mailing Address - Phone:630-452-2422
Mailing Address - Fax:
Practice Address - Street 1:40W310 LAFOX RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6588
Practice Address - Country:US
Practice Address - Phone:630-444-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056007899225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist