=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699988725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY DIANE HENRY C.O.T.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2502 SILVERSIDE RD SUITE 4
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19810-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-478-3702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 PEWTER CT
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19904-7614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-674-5637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | U2000005A
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------