Provider Demographics
NPI:1427539808
Name:MAYFIELD, KELLIE ALANA (COTA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ALANA
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 HENRETTA PL
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:78362-6124
Mailing Address - Country:US
Mailing Address - Phone:361-813-7312
Mailing Address - Fax:
Practice Address - Street 1:3922 W RIVER DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-5725
Practice Address - Country:US
Practice Address - Phone:361-767-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212252224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant