Provider Demographics
NPI:1699302687
Name:LISICIA, KELSEY TAYLOR (OTR/L)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:TAYLOR
Last Name:LISICIA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ANNE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:749 MCLAURIN ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-5023
Mailing Address - Country:US
Mailing Address - Phone:404-861-7588
Mailing Address - Fax:
Practice Address - Street 1:500 LANIER AVE W STE 603
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7644
Practice Address - Country:US
Practice Address - Phone:404-861-7588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006851225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist