Provider Demographics
NPI:1841651478
Name:MIDKIFF, KELLY LISA (COTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LISA
Last Name:MIDKIFF
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 1:520 ATASCOCITA RD LOT E14
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-3658
Mailing Address - Country:US
Mailing Address - Phone:281-441-2989
Mailing Address - Fax:
Practice Address - Street 1:520 ATASCOCITA RD LOT E14
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-3658
Practice Address - Country:US
Practice Address - Phone:281-441-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209419225X00000X, 225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics