Provider Demographics
NPI:1144580986
Name:EDDY, KELLY SUE (COTA/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:EDDY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 ALLENDALE DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-4457
Mailing Address - Country:US
Mailing Address - Phone:989-791-7054
Mailing Address - Fax:
Practice Address - Street 1:1673 ALLENDALE DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-4457
Practice Address - Country:US
Practice Address - Phone:989-791-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-28
Last Update Date:2012-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202004388171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor