Provider Demographics
NPI:1821630385
Name:BRANDON, KELLY K (LOTR)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:K
Last Name:BRANDON
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 VIKING LOOP
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-7421
Mailing Address - Country:US
Mailing Address - Phone:318-746-1199
Mailing Address - Fax:318-409-8060
Practice Address - Street 1:4350 VIKING LOOP
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7421
Practice Address - Country:US
Practice Address - Phone:318-746-1199
Practice Address - Fax:318-409-8060
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11593225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist