Provider Demographics
NPI:1811150287
Name:WUNDERLY, KELLY SUSAN (OTR)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUSAN
Last Name:WUNDERLY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8158 BIRCHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-2895
Mailing Address - Country:US
Mailing Address - Phone:317-709-1610
Mailing Address - Fax:
Practice Address - Street 1:5226 E 82ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1628
Practice Address - Country:US
Practice Address - Phone:317-842-6668
Practice Address - Fax:317-578-4113
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003781A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist