Provider Demographics
NPI:1861755613
Name:FITZGERALD, KELLY ROSE (MOT, OTR/L)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:ROSE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6613 BOBBIE LN
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-6539
Mailing Address - Country:US
Mailing Address - Phone:980-229-5301
Mailing Address - Fax:
Practice Address - Street 1:2110 BEN CRAIG DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2302
Practice Address - Country:US
Practice Address - Phone:704-595-9363
Practice Address - Fax:704-595-9365
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10673225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist