Healthcare Provider Details

I. General information

NPI: 1265802896
Provider Name (Legal Business Name): KELSEY L DUFAULT M.S., OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 08/14/2023
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17075 BUSHARD ST
FOUNTAIN VALLEY CA
92708-2836
US

IV. Provider business mailing address

1100 BLYTHE BLVD
CHARLOTTE NC
28203-5814
US

V. Phone/Fax

Practice location:
  • Phone: 855-901-7742
  • Fax: 714-962-4159
Mailing address:
  • Phone: 704-355-7760
  • Fax: 704-355-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number15635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: