Provider Demographics
NPI:1134496110
Name:HODGE, KELLY JEAN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:HODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6406 SANSON DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-5224
Mailing Address - Country:US
Mailing Address - Phone:407-883-0978
Mailing Address - Fax:352-508-5113
Practice Address - Street 1:2760 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-742-7837
Practice Address - Fax:352-508-5113
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12026224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant