Individual
KELLY RYAN FOGARTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
2125 W NEW HAVEN AVE, MELBOURNE, FL 32904-3803
(321) 729-4333
Mailing address
1476 LITCHFIELD DR, WEST MELBOURNE, FL 32904-6458
(954) 253-0140
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
11513
FL
224Z00000X
Occupational Therapy Assistant
Primary
OTA11513
FL
224ZE0001X
Environmental Modification Occupational Therapy Assistant
11513
FL
Other
Enumeration date
04/06/2022
Last updated
04/06/2022
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