Provider Demographics
NPI:1528844206
Name:MCCORMICK, KELLY L (OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 NATURE TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1676
Mailing Address - Country:US
Mailing Address - Phone:248-563-9052
Mailing Address - Fax:
Practice Address - Street 1:500 GRANT AVE
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-1398
Practice Address - Country:US
Practice Address - Phone:920-685-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8213-26225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation