=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447968433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY JOHNSON BALLIE OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2022
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1211 VIRGINIA ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-1313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-275-0927
-----------------------------------------------------
Fax | 336-275-4834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 LEAWOOD DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27410-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-944-1034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 5446
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------