Provider Demographics
NPI:1104676584
Name:MIERS, KELLI BAGLEY (OT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:BAGLEY
Last Name:MIERS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-9170
Mailing Address - Country:US
Mailing Address - Phone:318-218-1772
Mailing Address - Fax:
Practice Address - Street 1:8961 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3001
Practice Address - Country:US
Practice Address - Phone:318-671-8772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOOT.200499225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist