Provider Demographics
NPI:1437304532
Name:KELLY, TABATHA DANIELLE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:TABATHA
Middle Name:DANIELLE
Last Name:KELLY
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 1:244 DEAN CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:LA
Mailing Address - Zip Code:71260-4222
Mailing Address - Country:US
Mailing Address - Phone:318-292-5250
Mailing Address - Fax:
Practice Address - Street 1:1036 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:AR
Practice Address - Zip Code:71646-8980
Practice Address - Country:US
Practice Address - Phone:870-853-0857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A468224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant