Healthcare Provider Details

I. General information

NPI: 1265961890
Provider Name (Legal Business Name): KELLEY PLOURDE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 CATARACT ST
WORCESTER MA
01602-1127
US

IV. Provider business mailing address

124 CATARACT ST
WORCESTER MA
01602-1127
US

V. Phone/Fax

Practice location:
  • Phone: 774-366-5750
  • Fax:
Mailing address:
  • Phone: 774-366-5750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number13865
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: