Healthcare Provider Details

I. General information

NPI: 1003034331
Provider Name (Legal Business Name): KEL Z GASKIN PROCK MSR, OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ELIZABETH PROCK

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3603 KINGSLEY DR
MYRTLE BEACH SC
29588-7713
US

IV. Provider business mailing address

3603 KINGSLEY DR
MYRTLE BEACH SC
29588-7713
US

V. Phone/Fax

Practice location:
  • Phone: 843-424-5450
  • Fax:
Mailing address:
  • Phone: 843-424-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2713
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2713
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: