Provider Demographics
NPI:1871340364
Name:DECKARD, KELLIE A (OTR)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:A
Last Name:DECKARD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 N STATE HIGHWAY CC
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8015
Mailing Address - Country:US
Mailing Address - Phone:417-725-5774
Mailing Address - Fax:417-725-5915
Practice Address - Street 1:1887 N STATE HIGHWAY CC
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-8015
Practice Address - Country:US
Practice Address - Phone:417-725-5774
Practice Address - Fax:417-725-5915
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009026347225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist