Provider Demographics
NPI:1063826568
Name:CAVINESS, KELLY (OT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CAVINESS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6344 S FM 730
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-8702
Mailing Address - Country:US
Mailing Address - Phone:940-393-1851
Mailing Address - Fax:
Practice Address - Street 1:6344 S FM 730
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-8702
Practice Address - Country:US
Practice Address - Phone:940-393-1851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103995225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist