Provider Demographics
NPI:1962927145
Name:TARRY, KELLIE RENEE (OTR)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:RENEE
Last Name:TARRY
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 1:10524 LAKE GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-2336
Mailing Address - Country:US
Mailing Address - Phone:214-328-6560
Mailing Address - Fax:
Practice Address - Street 1:404 RACQUET CLUB BLVD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6408
Practice Address - Country:US
Practice Address - Phone:682-738-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107485225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist