Provider Demographics
NPI:1376914747
Name:GARLAND, KELLY (OT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GARLAND
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 RIVERSIDE DR
Mailing Address - Street 2:STE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1787
Mailing Address - Country:US
Mailing Address - Phone:478-633-6633
Mailing Address - Fax:478-633-4295
Practice Address - Street 1:1014 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2051
Practice Address - Country:US
Practice Address - Phone:478-201-6748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT006276OtherGA LICENSE