Basic Information
| Provider Information | |||||||||
| NPI: | 1043612047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOEBEL | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OTR/L, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1004 10TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ROYAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299352310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433109689 | ||||||||
| FaxNumber: | 8003179690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 10TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ROYAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299352310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433109689 | ||||||||
| FaxNumber: | 8003179690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2014 | ||||||||
| LastUpdateDate: | 09/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4364 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4364 | 01 | SC | PROFESSIONAL LICENSE | OTHER |