Provider Demographics
NPI:1679638977
Name:NELSON, KELLY COBB (MS OTRL)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:COBB
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS OTRL
Mailing Address - Street 1:3990 CAMDEN WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 BOMBAY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5822
Practice Address - Country:US
Practice Address - Phone:770-851-9553
Practice Address - Fax:770-698-4178
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT03452225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA930130OtherBCBS PIN