MEDICARE: MRS. KELLY LYNN IRVINE MS OTRL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OC009548	PA

General Provider Information

NPI Number	:	1558567685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY LYNN IRVINE MS OTRL

Provider Business Mailing Address
First Line	:	52 POPLAR RD
Second Line	:
City	:	GREENVILLE
State	:	PA
Zip	:	16125-9246
Country	:	US
Telephone Number	:	724-589-0547
Fax Number	:

Provider Business Practice Location Address
First Line	:	453 MAPLE ST
Second Line	:
City	:	GROVE CITY
State	:	PA
Zip	:	16127-2324
Country	:	US
Telephone Number	:	724-988-9648
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/08/2007

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