Provider Demographics
NPI:1962211367
Name:THIELMAN, KELLY WINSLOW (OTA/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:WINSLOW
Last Name:THIELMAN
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5403 HOLLY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-1520
Mailing Address - Country:US
Mailing Address - Phone:919-358-0400
Mailing Address - Fax:
Practice Address - Street 1:5403 HOLLY RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-1520
Practice Address - Country:US
Practice Address - Phone:919-358-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-01
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
NC7172224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant