Healthcare Provider Details

I. General information

NPI: 1720660970
Provider Name (Legal Business Name): KELSEY KROB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8274 E SAN RD
SOUTH RANGE WI
54874-8621
US

IV. Provider business mailing address

5149 W ARROWHEAD RD
HERMANTOWN MN
55811-1346
US

V. Phone/Fax

Practice location:
  • Phone: 715-398-3523
  • Fax:
Mailing address:
  • Phone: 218-348-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number106549
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: