Provider Demographics
NPI:1104209600
Name:KELLEY, KELSEY JEAN (OTR/L)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JEAN
Last Name:KELLEY
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 1:9240 CAMERON WOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-7904
Mailing Address - Country:US
Mailing Address - Phone:978-807-7558
Mailing Address - Fax:
Practice Address - Street 1:5113 PIPER STATION DR
Practice Address - Street 2:#103
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6689
Practice Address - Country:US
Practice Address - Phone:704-752-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9809225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics