Provider Demographics
NPI:1255847851
Name:KELLY, ERICA (MOT OTR/L)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MOT OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SAGAMORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 SAGAMORE DRIVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483
Practice Address - Country:US
Practice Address - Phone:203-231-4831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004588225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist