Healthcare Provider Details

I. General information

NPI: 1720327117
Provider Name (Legal Business Name): MS. BARBARA EILEEN KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 VICTORIA ST
BRANDON FL
33510-4100
US

IV. Provider business mailing address

1565 GEORGETOWN DR
LAKELAND FL
33811-4475
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-4220
  • Fax:
Mailing address:
  • Phone: 814-329-8254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number11174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: