Provider Demographics
NPI:1801962683
Name:WILK, 'KELLY' (OT)
Entity type:Individual
Prefix:MS
First Name:'KELLY'
Middle Name:
Last Name:WILK
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 1:2102 PROMONTORY PT
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-3547
Mailing Address - Country:US
Mailing Address - Phone:239-777-4009
Mailing Address - Fax:972-612-6804
Practice Address - Street 1:2102 PROMONTORY PT
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-3547
Practice Address - Country:US
Practice Address - Phone:239-777-4009
Practice Address - Fax:972-612-6804
Is Sole Proprietor?:No
Enumeration Date:2006-11-25
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7324225X00000X
TX113753225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2823296Medicaid
FL886525600Medicaid
FL888439100Medicaid