Provider Demographics
NPI:1962549584
Name:KELLEY, CAROLYN (OT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
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:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-0819
Mailing Address - Country:US
Mailing Address - Phone:360-893-6576
Mailing Address - Fax:360-893-6506
Practice Address - Street 1:710 NW JUNIPER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2717
Practice Address - Country:US
Practice Address - Phone:425-392-2346
Practice Address - Fax:425-392-0185
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001034225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist