Healthcare Provider Details

I. General information

NPI: 1700858826
Provider Name (Legal Business Name): KELLY MARIE MCCOY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MARIE KULUZ OT

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15476 DEDEAUX RD. SUITE B
GULFPORT MS
39503
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 228-679-3001
  • Fax: 228-679-3039
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT3034
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: