Provider Demographics
NPI:1972083475
Name:MEYER, KELLY LEIGH (COTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEIGH
Last Name:MEYER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W GOODWIN AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6530
Mailing Address - Country:US
Mailing Address - Phone:361-576-0694
Mailing Address - Fax:361-576-6530
Practice Address - Street 1:PORT LAVACA NURSING AND REHABILITATION CENTER
Practice Address - Street 2:524 VILLAGE RD
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979
Practice Address - Country:US
Practice Address - Phone:361-552-3741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213902224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant