Provider Demographics
NPI:1942766076
Name:GREGG, KELLY MARIE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:GREGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4285 MILLIKEN CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2532
Mailing Address - Country:US
Mailing Address - Phone:970-232-0237
Mailing Address - Fax:
Practice Address - Street 1:6500 ARAPAHOE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1407
Practice Address - Country:US
Practice Address - Phone:970-232-0237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023083225XP0200X
COOT.0006908225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics