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NPI Code Detail

MEDICARE: KELLY DIRKSEN OTR

MEDICARE: KELLY DIRKSEN OTR
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
1225X00000XOccupational Therapist01768IA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
101768OTHERIASTATE OF IOWA LICENSE OCCUPATIONAL THERAPY

General Provider Information

NPI Number : 1942662432
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY DIRKSEN OTR
Provider Business Mailing Address
First Line : 1130 W 53RD ST
Second Line :
City : DAVENPORT
State : IA
Zip : 52806-2401
Country : US
Telephone Number : 563-391-5342
Fax Number :
Provider Business Practice Location Address
First Line : 1130 W 53RD ST
Second Line :
City : DAVENPORT
State : IA
Zip : 52806-2401
Country : US
Telephone Number : 563-391-5342
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/23/2016
Last Update Date : 03/23/2016

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Directions to “ KELLY DIRKSEN OTR” Practice Location

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