Healthcare Provider Details

I. General information

NPI: 1164569596
Provider Name (Legal Business Name): BARBARA J KELLY OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DOCTORS CT
JOHNSON CREEK WI
53038-9567
US

IV. Provider business mailing address

400 DOCTORS CT
JOHNSON CREEK WI
53038-9567
US

V. Phone/Fax

Practice location:
  • Phone: 920-699-4245
  • Fax:
Mailing address:
  • Phone: 920-699-4245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number998-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: