Provider Demographics
NPI:1578068185
Name:KELLY, MARY JO (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 BELLAMY TIPTON RD
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-5046
Mailing Address - Country:US
Mailing Address - Phone:239-292-7489
Mailing Address - Fax:
Practice Address - Street 1:1191 BELLAMY TIPTON RD
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-5046
Practice Address - Country:US
Practice Address - Phone:239-292-7489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5809225X00000X
TNOT0000004939225XP0019X, 225X00000X
VA0119007492225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119007492OtherSTATE OT LICENSE
TN134421797OtherDRIVERS LICENSE
TNOT0000004939OtherSTATE LICENSE OT