MEDICARE: KELLIE'S KIDZ, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist		MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417054180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLIE'S KIDZ, LLC

Provider Business Mailing Address
First Line	:	1528 S 11TH ST
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-9543
Country	:	US
Telephone Number	:	228-872-3042
Fax Number	:

Provider Business Practice Location Address
First Line	:	1528 S 11TH ST
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-9543
Country	:	US
Telephone Number	:	228-872-3042
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	MRS. KELLIE THOMPSON HUGHES
Credential	:	OTR/L
Telephone Number	:	228-872-3042

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	08/22/2020

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