Healthcare Provider Details

I. General information

NPI: 1679285167
Provider Name (Legal Business Name): KELLYN MARTIN MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLYN MUNSEY

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 12/16/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S CREEK DR STE 116
MONTICELLO KY
42633-9472
US

IV. Provider business mailing address

116 HOSPITAL ST
MONTICELLO KY
42633
US

V. Phone/Fax

Practice location:
  • Phone: 606-348-3314
  • Fax:
Mailing address:
  • Phone: 606-348-9343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number163223
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: