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General NPI Number Information
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NPI Number | 1902962624
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Entity Type | Individual
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Provider Name | KELLEY BROYLD B.S.
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Gender | Female
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 04/13/2012
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Provider Practice Location Address
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Address Line | 155 PALISADES DR
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City | DALLAS
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State | GA
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Zip | 30157-0927
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Country | US
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Telephone | 404-579-8307
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Fax |
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Provider Business Mailing Address
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Address Line | 155 PALISADES DR
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City | DALLAS
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State | GA
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Zip | 30157-0927
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Country | US
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Telephone | 404-579-8307
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT003284
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License Number State | GA
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