Provider Demographics
NPI:1295254480
Name:BROGAN, KELLI E
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:E
Last Name:BROGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 SANDHILL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SOSO
Mailing Address - State:MS
Mailing Address - Zip Code:39480-5104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:478 SANDHILL CHURCH RD
Practice Address - Street 2:
Practice Address - City:SOSO
Practice Address - State:MS
Practice Address - Zip Code:39480-5104
Practice Address - Country:US
Practice Address - Phone:601-422-3860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3154225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist