Provider Demographics
NPI:1578679379
Name:JEFFERS-GRAY, KELLY SUE (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:JEFFERS-GRAY
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 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:400 OVESEN DR
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:IA
Practice Address - Zip Code:52778-9612
Practice Address - Country:US
Practice Address - Phone:563-732-4317
Practice Address - Fax:563-732-4318
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01527225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665711Medicaid
IA38037OtherBLUE CROSS BLUE SHIELD
IAI15598OtherMEDICARE
IA0665711Medicaid