Provider Demographics
NPI:1215492525
Name:ZAMORA, KELLY (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:ZAMORA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:IBARRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4099 HUERFANO AVE UNIT 113
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5229
Mailing Address - Country:US
Mailing Address - Phone:310-920-3623
Mailing Address - Fax:
Practice Address - Street 1:11895 AVENUE OF INDUSTRY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3423
Practice Address - Country:US
Practice Address - Phone:858-673-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18158225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist