Provider Demographics
NPI:1811318983
Name:STALEY, KEITH (OT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:STALEY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:312-640-0407
Practice Address - Street 1:13375 UNIVERSITY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8261
Practice Address - Country:US
Practice Address - Phone:515-327-1454
Practice Address - Fax:515-327-1458
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01633225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist