Individual
KELLEY D LAWLESS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
615 N PROMENADE ST, HAVANA, IL 62644-1243
(309) 543-8578
Mailing address
615 N PROMENADE ST, HAVANA, IL 62644-1243
(309) 543-8578
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
057002848
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
376017857001
—
IL
Enumeration date
09/01/2009
Last updated
09/01/2009
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