Provider Demographics
NPI:1699441741
Name:STALEY, KELLY ANNE (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:STALEY
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 GENTRY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1639
Mailing Address - Country:US
Mailing Address - Phone:636-328-7787
Mailing Address - Fax:
Practice Address - Street 1:851 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5257
Practice Address - Country:US
Practice Address - Phone:931-542-2168
Practice Address - Fax:615-619-2388
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7039225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist