Provider Demographics
NPI:1205602430
Name:DAVIS, KELLY (OTR)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CRESSON CT
Mailing Address - Street 2:
Mailing Address - City:CHINA SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:76633-4807
Mailing Address - Country:US
Mailing Address - Phone:254-733-6625
Mailing Address - Fax:
Practice Address - Street 1:601 W LOOP 340
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6840
Practice Address - Country:US
Practice Address - Phone:254-523-4478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
OR481209225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist