Healthcare Provider Details

I. General information

NPI: 1073178372
Provider Name (Legal Business Name): KELLY D'AQUILLA, OT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5637 COMMERCE STREET
ST. FRANCISVILLE LA
70775
US

IV. Provider business mailing address

PO BOX 276
SAINT FRANCISVILLE LA
70775-0276
US

V. Phone/Fax

Practice location:
  • Phone: 225-978-7686
  • Fax:
Mailing address:
  • Phone: 225-635-0149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY D'AQUILLA
Title or Position: OWNER
Credential: LOTR
Phone: 225-635-0149