MEDICARE: KELLY ANDERSON OT

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	OT05087	OH

General Provider Information

NPI Number	:	1992756266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANDERSON OT

Provider Business Mailing Address
First Line	:	23825 COMMERCE PARK
Second Line	:	STE B
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5837
Country	:	US
Telephone Number	:	216-292-6363
Fax Number	:	216-292-6306

Provider Business Practice Location Address
First Line	:	4100 WARRENSVILLE CENTER RD
Second Line	:	STE 102
City	:	CLEVELAND
State	:	OH
Zip	:	44122-7024
Country	:	US
Telephone Number	:	216-561-0101
Fax Number	:	216-561-8915

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	07/08/2007

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