Healthcare Provider Details

I. General information

NPI: 1578679379
Provider Name (Legal Business Name): KELLY SUE JEFFERS-GRAY MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 OVESEN DR
WILTON IA
52778-9612
US

IV. Provider business mailing address

850 43RD AVE STE 100
MOLINE IL
61265-8401
US

V. Phone/Fax

Practice location:
  • Phone: 563-732-4317
  • Fax: 563-732-4318
Mailing address:
  • Phone: 309-743-2070
  • Fax: 309-743-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number01527
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number01527
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: