Provider Demographics
NPI:1669049342
Name:KELL, BREANNA JEAN (COTA/L)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:JEAN
Last Name:KELL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 DALE ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4118
Mailing Address - Country:US
Mailing Address - Phone:863-308-1744
Mailing Address - Fax:
Practice Address - Street 1:1290 CELEBRATION BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34747-4692
Practice Address - Country:US
Practice Address - Phone:321-337-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16845224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant