Provider Demographics
NPI:1639672892
Name:GAGNE, KELSEY (MSOTRL)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GAGNE
Suffix:
Gender:F
Credentials:MSOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HOLCOMB WOODS PKWY STE 422
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4718
Mailing Address - Country:US
Mailing Address - Phone:770-641-8070
Mailing Address - Fax:770-641-8078
Practice Address - Street 1:1000 HOLCOMB WOODS PKWY STE 422
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4718
Practice Address - Country:US
Practice Address - Phone:770-641-8070
Practice Address - Fax:770-641-8078
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006613225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist