=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629785043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLIE DEHNE OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2022
-----------------------------------------------------
Last Update Date | 11/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 DIVISION ST
-----------------------------------------------------
City | PRAIRIE GROVE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72753-5501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-334-0014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 944 MACY LN
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72727-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-529-0703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OTR3634
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------