=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912620378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEARSTIN RENEE HOUGHTON COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 BLYMYER AVE
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44903-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-774-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1747 GRACE AVE
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-975-0448
-----------------------------------------------------
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 | OTA007676
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------