Provider Demographics
NPI:1518608082
Name:FOGARTY, KELLY RYAN (COTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RYAN
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RYAN
Other - Last Name:FOGARTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:KELLY R FOGARTY COTA
Mailing Address - Street 1:1476 LITCHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-6458
Mailing Address - Country:US
Mailing Address - Phone:954-253-0140
Mailing Address - Fax:
Practice Address - Street 1:2125 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3803
Practice Address - Country:US
Practice Address - Phone:321-729-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11513224Z00000X
FL11513224Z00000X, 224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification