Provider Demographics
NPI:1467285981
Name:BRISTER, KELLY MACKENZIE (COTA)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MACKENZIE
Last Name:BRISTER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-0457
Mailing Address - Country:US
Mailing Address - Phone:601-587-2563
Mailing Address - Fax:601-587-0472
Practice Address - Street 1:PO BOX 457
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-0457
Practice Address - Country:US
Practice Address - Phone:601-587-2563
Practice Address - Fax:601-587-0472
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOTA-4021224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant