Healthcare Provider Details

I. General information

NPI: 1962293860
Provider Name (Legal Business Name): ASHLEY NICHOLE KIDD OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N ALLEGHANEY AVE
ODESSA TX
79761-4408
US

IV. Provider business mailing address

620 N ALLEGHANEY AVE
ODESSA TX
79761-4408
US

V. Phone/Fax

Practice location:
  • Phone: 432-332-8244
  • Fax: 432-580-7428
Mailing address:
  • Phone: 432-332-8244
  • Fax: 432-580-7428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number118097
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: