Provider Demographics
NPI:1447516042
Name:KELLEY, SAVANNAH DAWN (OTA)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:DAWN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:KANOPOLIS
Mailing Address - State:KS
Mailing Address - Zip Code:67454-0091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1156 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:KS
Practice Address - Zip Code:67439-8661
Practice Address - Country:US
Practice Address - Phone:785-472-3167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03189224Z00000X
KS18-00856224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant