Provider Demographics
NPI:1003489048
Name:LOPEZ-LOMELI, KEISY ARISLU (OTD)
Entity Type:Individual
Prefix:
First Name:KEISY
Middle Name:ARISLU
Last Name:LOPEZ-LOMELI
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4575 DURON PL SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1177
Mailing Address - Country:US
Mailing Address - Phone:712-389-7919
Mailing Address - Fax:
Practice Address - Street 1:351 THORNTON RD STE 125
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1589
Practice Address - Country:US
Practice Address - Phone:770-577-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006916225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics