Provider Demographics
NPI:1932552536
Name:KELLEHER, KELLY ANN (COTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1555 HARBOR SUN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4404
Mailing Address - Country:US
Mailing Address - Phone:843-569-4546
Mailing Address - Fax:843-569-4535
Practice Address - Street 1:9225 UNIVERSITY BLVD STE E2C
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9149
Practice Address - Country:US
Practice Address - Phone:843-569-4546
Practice Address - Fax:843-569-4535
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3475224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant