Provider Demographics
NPI:1548863343
Name:WILSON, KELLY (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 TETHER WAY
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-5733
Mailing Address - Country:US
Mailing Address - Phone:267-885-4971
Mailing Address - Fax:
Practice Address - Street 1:232 TETHER WAY
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-5733
Practice Address - Country:US
Practice Address - Phone:267-885-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
PAOC016653225X00000X
NY024451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist