Provider Demographics
NPI:1336477033
Name:HODGE, KELLY D (OT/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:HODGE
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 BAYSHORE BLVD
Mailing Address - Street 2:1611
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2344
Mailing Address - Country:US
Mailing Address - Phone:813-389-3239
Mailing Address - Fax:
Practice Address - Street 1:345 BAYSHORE BLVD
Practice Address - Street 2:1611
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2344
Practice Address - Country:US
Practice Address - Phone:813-389-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0006255225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist