Provider Demographics
NPI:1952546145
Name:KELLY, CHRYSTLE M (OT/L)
Entity Type:Individual
Prefix:
First Name:CHRYSTLE
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 RAINTREE LN
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-5340
Mailing Address - Country:US
Mailing Address - Phone:423-316-3947
Mailing Address - Fax:
Practice Address - Street 1:2626 WALKER RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1116
Practice Address - Country:US
Practice Address - Phone:423-490-1599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1073174400000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No174400000XOther Service ProvidersSpecialist