Healthcare Provider Details

I. General information

NPI: 1649495763
Provider Name (Legal Business Name): VIRGINIA R MCKIERNAN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 S FLOYD ST STE 100
LOUISVILLE KY
40202-3827
US

IV. Provider business mailing address

571 S FLOYD ST STE 100
LOUISVILLE KY
40202-3827
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-7897
  • Fax: 502-852-2911
Mailing address:
  • Phone: 502-852-7897
  • Fax: 502-852-2911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberR2743
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: