Provider Demographics
NPI:1922333624
Name:REILLY GARDNER, KELLY L (COTA/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:REILLY GARDNER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:HUFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:4211 EAST 4TH STREET #9
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814
Mailing Address - Country:US
Mailing Address - Phone:562-355-2719
Mailing Address - Fax:
Practice Address - Street 1:4211 E 4TH ST APT 9
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-4912
Practice Address - Country:US
Practice Address - Phone:562-355-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1807224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant