Provider Demographics
NPI:1104053529
Name:STONE, KELLY RUSSO (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RUSSO
Last Name:STONE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:505 LOUVOIS ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5468
Mailing Address - Country:US
Mailing Address - Phone:678-462-2923
Mailing Address - Fax:866-753-4652
Practice Address - Street 1:505 LOUVOIS ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5468
Practice Address - Country:US
Practice Address - Phone:678-462-2923
Practice Address - Fax:866-753-4652
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z1156225XE0001X, 225XF0002X, 225XM0800X, 225XN1300X, 225XP0200X, 225XF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2450514Medicaid