Provider Demographics
NPI:1831412766
Name:FREDERICK, KELLEY A (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 BUTLER STREET
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079
Mailing Address - Country:US
Mailing Address - Phone:603-893-2900
Mailing Address - Fax:603-893-1628
Practice Address - Street 1:70 BUTLER STREET
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079
Practice Address - Country:US
Practice Address - Phone:603-893-2900
Practice Address - Fax:603-893-1628
Is Sole Proprietor?:No
Enumeration Date:2010-03-06
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1957225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist