Healthcare Provider Details

I. General information

NPI: 1467515122
Provider Name (Legal Business Name): KELLY YAGUD OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAHER DR
NORWALK CT
06850-2416
US

IV. Provider business mailing address

1 MAHER DR
NORWALK CT
06850-2416
US

V. Phone/Fax

Practice location:
  • Phone: 203-258-7261
  • Fax:
Mailing address:
  • Phone: 203-258-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number002609
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0002609
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: