Healthcare Provider Details

I. General information

NPI: 1669066007
Provider Name (Legal Business Name): CEDRIC BURTON SR. OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17018 PRESERVE POINTE DR
LOUISVILLE KY
40245-4740
US

IV. Provider business mailing address

17018 PRESERVE POINTE DR
LOUISVILLE KY
40245-4740
US

V. Phone/Fax

Practice location:
  • Phone: 502-390-1861
  • Fax:
Mailing address:
  • Phone: 502-390-1861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number170656
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number170656
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number170656
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number170656
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: