Provider Demographics
NPI:1871823674
Name:BRANNON, KELLIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BRANNON
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 1:18420 SW 79TH CT
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-7446
Mailing Address - Country:US
Mailing Address - Phone:305-232-1218
Mailing Address - Fax:
Practice Address - Street 1:5920 SW 68TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3524
Practice Address - Country:US
Practice Address - Phone:305-270-9026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT3867225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882186100Medicaid