Provider Demographics
NPI:1528739612
Name:MARTIN, KELLEY MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 MARINELLA DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3668
Mailing Address - Country:US
Mailing Address - Phone:305-409-9376
Mailing Address - Fax:
Practice Address - Street 1:1483 TOBIAS GADSON BLVD STE 205B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4641
Practice Address - Country:US
Practice Address - Phone:843-766-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6312225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist