Basic Information
| Provider Information | |||||||||
| NPI: | 1437726312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANDORF | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | KELLI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 329 HARRIS ST | ||||||||
| Address2: | |||||||||
| City: | MINERAL POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535651012 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1350 S MADISON ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 538132167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087234143 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2021 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 6994-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.