Provider Demographics
NPI:1063893790
Name:KWASNIUK, KELLY MARIE (OTR)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MARIE
Last Name:KWASNIUK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FOREST CENTER DR
Mailing Address - Street 2:APT 16108
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-5245
Mailing Address - Country:US
Mailing Address - Phone:810-923-5151
Mailing Address - Fax:810-923-5151
Practice Address - Street 1:300 FOREST CENTER DRIVE
Practice Address - Street 2:APT 16108
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-1111
Practice Address - Country:US
Practice Address - Phone:810-923-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113822225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist