Provider Demographics
NPI:1194895789
Name:STANCOVICH, KELLI DAWN (OT)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:DAWN
Last Name:STANCOVICH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:DAWN
Other - Last Name:BOUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:179 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-2041
Mailing Address - Country:US
Mailing Address - Phone:814-736-9536
Mailing Address - Fax:
Practice Address - Street 1:429 S MARKET ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:PA
Practice Address - Zip Code:16662-1005
Practice Address - Country:US
Practice Address - Phone:814-793-5206
Practice Address - Fax:814-793-3818
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC008172225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist