Provider Demographics
NPI:1700858826
Name:MCCOY, KELLY MARIE (OT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:KULUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:6300 E LAKE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6770
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-1130
Practice Address - Street 1:15476 DEDEAUX RD.
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-679-3001
Practice Address - Fax:228-679-3039
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3034225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1700858826Medicaid