Basic Information
| Provider Information | |||||||||
| NPI: | 1437447828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | OLIVER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 724 GRAVEL HILL RD | ||||||||
| Address2: | |||||||||
| City: | PHIL CAMPBELL | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355814304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564361706 | ||||||||
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| Practice Location | |||||||||
| Address1: | 705 GANDY ST NE | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356531913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563321611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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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 | 224Z00000X | 3197 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.