=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205180718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA M KELLY OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2012
-----------------------------------------------------
Last Update Date | 10/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3261 HWY 49 SOUTH VA STATE HOME/COLLINS
-----------------------------------------------------
City | COLLINS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-206-9195
-----------------------------------------------------
Fax | 601-957-8391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 315
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-206-9195
-----------------------------------------------------
Fax | 601-957-8391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT0277
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------