Provider Demographics
NPI:1649450164
Name:ANTHONY, KEELY N (COTA)
Entity type:Individual
Prefix:MISS
First Name:KEELY
Middle Name:N
Last Name:ANTHONY
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 1:500 ARCADE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2477
Mailing Address - Country:US
Mailing Address - Phone:574-296-9100
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2477
Practice Address - Country:US
Practice Address - Phone:574-296-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001081A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant