Provider Demographics
NPI:1194406652
Name:CULLERTON, KELLY ANNE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:CULLERTON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 W 200 S APT 505
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1483
Mailing Address - Country:US
Mailing Address - Phone:801-608-8056
Mailing Address - Fax:
Practice Address - Street 1:5484 ADAMS AVE PKWY
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4729
Practice Address - Country:US
Practice Address - Phone:801-608-8056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13477410-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist