Provider Demographics
NPI:1285871244
Name:STANLEY, KEITH KELLY (OT)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:KELLY
Last Name:STANLEY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7229
Mailing Address - Country:US
Mailing Address - Phone:575-534-1919
Mailing Address - Fax:575-534-0135
Practice Address - Street 1:1268 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7229
Practice Address - Country:US
Practice Address - Phone:575-534-1919
Practice Address - Fax:575-534-0135
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2496225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2496OtherSTATE LICENSE