Healthcare Provider Details

I. General information

NPI: 1437726312
Provider Name (Legal Business Name): KELLI STANDORF OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLI PETERSON

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 S MADISON ST
LANCASTER WI
53813-2167
US

IV. Provider business mailing address

329 HARRIS ST
MINERAL POINT WI
53565-1012
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-4143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6994-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: