Provider Demographics
NPI:1861423303
Name:PETERS, KELLY ANN (MA OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9346 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-9422
Mailing Address - Country:US
Mailing Address - Phone:952-223-2506
Mailing Address - Fax:952-443-2038
Practice Address - Street 1:9346 OAK AVE
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387
Practice Address - Country:US
Practice Address - Phone:952-223-2506
Practice Address - Fax:952-443-2038
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103086225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist