Basic Information
| Provider Information | |||||||||
| NPI: | 1619495751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARHAT | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 EASTGATE MALL | ||||||||
| Address2: | STE 105 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583579450 | ||||||||
| FaxNumber: | 8584126376 | ||||||||
| Practice Location | |||||||||
| Address1: | 5446 N ACADEMY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195985555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 21360 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 014254700 | 05 | FL | MEDICAID |