Provider Demographics
NPI:1851914899
Name:GRAGG, KELLY LEONHARDT (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEONHARDT
Last Name:GRAGG
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 1:1261 WHITETOP RD
Mailing Address - Street 2:
Mailing Address - City:CHILHOWIE
Mailing Address - State:VA
Mailing Address - Zip Code:24319-3626
Mailing Address - Country:US
Mailing Address - Phone:828-430-1783
Mailing Address - Fax:
Practice Address - Street 1:927 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4117
Practice Address - Country:US
Practice Address - Phone:276-783-7529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008556225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty