Healthcare Provider Details

I. General information

NPI: 1780046235
Provider Name (Legal Business Name): KELSIE DEERING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 FAN RD
WAUKON IA
52172-7729
US

IV. Provider business mailing address

1417 FAN RD
WAUKON IA
52172-7729
US

V. Phone/Fax

Practice location:
  • Phone: 319-540-2860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number080450
License Number StateIA

VIII. Authorized Official

Name: KELSIE DEERING
Title or Position: OCCUPATIONAL THERAPY ASSISTANT
Credential: COTA
Phone: 319-540-2860