Provider Demographics
NPI:1972623676
Name:WEINER, KELLY B (MS,OTRL)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:B
Last Name:WEINER
Suffix:
Gender:F
Credentials:MS,OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 FAIRFAX LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1218
Mailing Address - Country:US
Mailing Address - Phone:847-955-0953
Mailing Address - Fax:
Practice Address - Street 1:1321 FAIRFAX LN
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1218
Practice Address - Country:US
Practice Address - Phone:847-955-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.003628225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics