Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225XH1200X | Occupational Therapist - Hand | 00003746 | WA |
Y | 225XH1200X | Occupational Therapist - Hand | 12210 | CA |
N | 225XH1200X | Occupational Therapist - Hand | OT1059774 | OR |
NPI | 1023494705 |
---|---|
Provider Name | Kelli Meredith Clevette |
First Address | Ventura, CA 93003-7844 |
Second Address | Camarillo, CA 93010-1502 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2015 |
Last Update Date | 27/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12210 | STATE LICENSE (01) | CA |