Provider Demographics
NPI:1144868555
Name:WILLIS, KELLIE LOVE (COTA/L)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:LOVE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:KELLIE
Other - Middle Name:LOVE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:12495 HOLEY RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-9607
Mailing Address - Country:US
Mailing Address - Phone:850-322-8219
Mailing Address - Fax:
Practice Address - Street 1:3492 MARTIN HURST RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-1702
Practice Address - Country:US
Practice Address - Phone:850-294-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14701224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant