Provider Demographics
NPI:1992334809
Name:ROBERSON, KELLY ANN (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 E ROSE MARIE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-6750
Mailing Address - Country:US
Mailing Address - Phone:602-989-3015
Mailing Address - Fax:
Practice Address - Street 1:7654 N 19TH AVE # QVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7025
Practice Address - Country:US
Practice Address - Phone:602-771-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5887224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant