Provider Demographics
NPI:1548771843
Name:NESBITT, KELLY (OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NESBITT
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 1:2123 S FINLEY RD APT 415
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6458
Mailing Address - Country:US
Mailing Address - Phone:317-997-7643
Mailing Address - Fax:
Practice Address - Street 1:830 S ADDISON AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2877
Practice Address - Country:US
Practice Address - Phone:630-620-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012180225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist