Provider Demographics
NPI:1215346036
Name:MARTIN, KELLY (OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARTIN
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 1:150 MEADOWS RD S
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1127
Mailing Address - Country:US
Mailing Address - Phone:815-644-1332
Mailing Address - Fax:
Practice Address - Street 1:300 E MAZON AVE
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1104
Practice Address - Country:US
Practice Address - Phone:815-584-9268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.006115225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist