Provider Demographics
NPI:1134286099
Name:KOZLOFF, KELLEY PHILLIPS (MS, OTRL)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:PHILLIPS
Last Name:KOZLOFF
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 LOWELL ST
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2417
Mailing Address - Country:US
Mailing Address - Phone:248-506-3109
Mailing Address - Fax:
Practice Address - Street 1:115 MILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1041
Practice Address - Country:US
Practice Address - Phone:617-855-2847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAH8943-OT225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAH 8943-OTOtherOCCUPATIONAL THERAPY LICE