Healthcare Provider Details

I. General information

NPI: 1376914747
Provider Name (Legal Business Name): KELLY GARLAND OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 FORSYTH ST
MACON GA
31201-2051
US

IV. Provider business mailing address

2490 RIVERSIDE DR STE B
MACON GA
31204-1787
US

V. Phone/Fax

Practice location:
  • Phone: 478-201-6748
  • Fax:
Mailing address:
  • Phone: 478-633-6633
  • Fax: 478-633-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT006276
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: