Provider Demographics
NPI:1972913945
Name:CLELLAN, KATHERESA (KATHERESA)
Entity type:Individual
Prefix:
First Name:KATHERESA
Middle Name:
Last Name:CLELLAN
Suffix:
Gender:F
Credentials:KATHERESA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14300 MOUNT PERRY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43760-9714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 N. HURSTBOURNE PARKWAY SUITE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT03410#225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist