Provider Demographics
NPI:1063662567
Name:GRIFFITH, KELLIE HARDESTY (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:KELLIE
Middle Name:HARDESTY
Last Name:GRIFFITH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-2015
Mailing Address - Country:US
Mailing Address - Phone:870-821-1311
Mailing Address - Fax:
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360-2102
Practice Address - Country:US
Practice Address - Phone:870-295-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR)TR1306225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist