Basic Information
| Provider Information | |||||||||
| NPI: | 1003807694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMERSON | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 105132 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303485132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153292294 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 21ST AVE N | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153296600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 01/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT2688 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3656390 | 05 | TN | MEDICAID |