Healthcare Provider Details

I. General information

NPI: 1316762487
Provider Name (Legal Business Name): KILEY PICKETT OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HOSPITAL ST
MOULTON AL
35650-1268
US

IV. Provider business mailing address

2596 COUNTY ROAD 1117
VINEMONT AL
35179-8873
US

V. Phone/Fax

Practice location:
  • Phone: 256-974-1146
  • Fax:
Mailing address:
  • Phone: 256-636-5067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4287
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: