Provider Demographics
NPI:1043524358
Name:MADERE, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MADERE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39315 SWAN RD
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-5715
Mailing Address - Country:US
Mailing Address - Phone:504-259-3281
Mailing Address - Fax:
Practice Address - Street 1:39315 SWAN RD
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:LA
Practice Address - Zip Code:70452-5715
Practice Address - Country:US
Practice Address - Phone:504-259-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTA.200192224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant