Provider Demographics
NPI:1932742095
Name:MATHEWS, KELLY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24120 M AVE UNIT 7
Mailing Address - Street 2:
Mailing Address - City:GRUNDY CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50638-8760
Mailing Address - Country:US
Mailing Address - Phone:319-269-6197
Mailing Address - Fax:
Practice Address - Street 1:909 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAER
Practice Address - State:IA
Practice Address - Zip Code:50675-1311
Practice Address - Country:US
Practice Address - Phone:319-478-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00742225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist