Healthcare Provider Details

I. General information

NPI: 1083102685
Provider Name (Legal Business Name): ANDREA M O'BRIEN OTR/L, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA MICHELLE MADDUX OTR/L

II. Dates (important events)

Enumeration Date: 04/29/2018
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4504 STARLITE LN
LOUISVILLE KY
40291-1725
US

IV. Provider business mailing address

4504 STARLITE LN
LOUISVILLE KY
40291-1725
US

V. Phone/Fax

Practice location:
  • Phone: 502-930-6064
  • Fax:
Mailing address:
  • Phone: 502-930-6064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number132611
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: