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General NPI Number Information
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NPI Number | 1649449588
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Entity Type | Individual
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Provider Name | KELLY BRIDGETTE SMALL
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Gender | Female
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Dates
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Enumeration Date | 02/25/2008
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Last Update Date | 02/25/2008
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Provider Practice Location Address
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Address Line | 819 EAST ST
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City | BARABOO
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State | WI
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Zip | 53913-2213
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Country | US
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Telephone | 682-553-8393
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Fax |
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Provider Business Mailing Address
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Address Line | 819 EAST ST
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City | BARABOO
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State | WI
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Zip | 53913-2213
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Country | US
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Telephone | 682-553-8393
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 207218
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License Number State | TX
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