Provider Demographics
NPI:1699492694
Name:QUINTANILLA, KELLY (OTR)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:QUINTANILLA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 TOOMER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-9170
Mailing Address - Country:US
Mailing Address - Phone:856-417-2867
Mailing Address - Fax:
Practice Address - Street 1:335 TOOMER AVE
Practice Address - Street 2:
Practice Address - City:WEST BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08091-9170
Practice Address - Country:US
Practice Address - Phone:856-417-2867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01058800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist