Provider Demographics
NPI:1215273065
Name:MACK, KELLI MARIE (OTR)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:MACK
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 1:28910 COUNTY HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7301
Mailing Address - Country:US
Mailing Address - Phone:218-234-6747
Mailing Address - Fax:
Practice Address - Street 1:1415 MADISON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-4542
Practice Address - Country:US
Practice Address - Phone:218-844-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102620225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist