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General NPI Number Information
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NPI Number | 1689134389
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Entity Type | Individual
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Provider Name | KELSEY TYSICK COTA/L
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Gender | Female
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Dates
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Enumeration Date | 03/20/2019
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Last Update Date | 03/20/2019
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Provider Practice Location Address
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Address Line | 2701 CHESTNUT STATION CT
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City | LOUISVILLE
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State | KY
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Zip | 40299-6395
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Country | US
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Telephone | 800-335-1060
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Fax |
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Provider Business Mailing Address
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Address Line | 3802 JONES RD
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City | NORTH BRANCH
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State | MI
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Zip | 48461-8930
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Country | US
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Telephone | 810-969-5311
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 5202008199
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License Number State | MI
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