Provider Demographics
NPI:1285281980
Name:SLACK, KAELYNN M
Entity type:Individual
Prefix:
First Name:KAELYNN
Middle Name:M
Last Name:SLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 E 56TH ST BLDG A
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-8628
Mailing Address - Country:US
Mailing Address - Phone:308-233-5060
Mailing Address - Fax:308-233-5060
Practice Address - Street 1:920 E 56TH ST BLDG A
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-8628
Practice Address - Country:US
Practice Address - Phone:308-233-5060
Practice Address - Fax:308-233-5060
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2365225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist