Provider Demographics
NPI:1841642857
Name:SILLS, KELLY ELIZABETH
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:SILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ALEJO
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2913
Mailing Address - Country:US
Mailing Address - Phone:949-394-0054
Mailing Address - Fax:
Practice Address - Street 1:1351 W PINE AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5031
Practice Address - Country:US
Practice Address - Phone:208-888-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1481225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist