Provider Demographics
NPI:1053871368
Name:GRANT, KELLY LEE (OTR)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:GRANT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEE
Other - Last Name:PIEPENBRINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3320 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1918
Practice Address - Country:US
Practice Address - Phone:260-483-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007250A225X00000X
INRBT-17-44326106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician