Provider Demographics
NPI:1538557145
Name:HEADRICK, KELLIE MARIE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:MARIE
Last Name:HEADRICK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CARRIER MILLS
Mailing Address - State:IL
Mailing Address - Zip Code:62917-1181
Mailing Address - Country:US
Mailing Address - Phone:618-599-5621
Mailing Address - Fax:
Practice Address - Street 1:924 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2637
Practice Address - Country:US
Practice Address - Phone:618-252-7171
Practice Address - Fax:618-252-7272
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004130224Z00000X
KYBOTOTA00210165224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant