Provider Demographics
NPI:1275890576
Name:KELLEY, EMMA LOUISE (COTA/L)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:LOUISE
Last Name:KELLEY
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 1:2095 270TH ST
Mailing Address - Street 2:
Mailing Address - City:OTHO
Mailing Address - State:IA
Mailing Address - Zip Code:50569-7523
Mailing Address - Country:US
Mailing Address - Phone:515-351-0964
Mailing Address - Fax:515-549-3488
Practice Address - Street 1:1005 E 23RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-0800
Practice Address - Country:US
Practice Address - Phone:866-784-2329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000836224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant