Provider Demographics
NPI:1346756822
Name:SMITH, KELLEY SUE (COTA/L, ATP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA/L, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04953-3229
Mailing Address - Country:US
Mailing Address - Phone:207-321-1015
Mailing Address - Fax:
Practice Address - Street 1:24 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:ME
Practice Address - Zip Code:04953-3229
Practice Address - Country:US
Practice Address - Phone:207-321-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA622224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant