Healthcare Provider Details

I. General information

NPI: 1417689423
Provider Name (Legal Business Name): KELLIE KATHRYN TUNNEY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KIRKWOOD RD STE 150
SAINT LOUIS MO
63122-7251
US

IV. Provider business mailing address

917 ALLEN AVE UNIT #3
SAINT LOUIS MO
63104-3907
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-7554
  • Fax:
Mailing address:
  • Phone: 708-289-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2017031900
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: