Basic Information
Provider Information | |||||||||
NPI: | 1013263664 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDS | ||||||||
FirstName: | KAYLA | ||||||||
MiddleName: | BROOKE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTRL | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ADCOCK | ||||||||
OtherFirstName: | KAYLA | ||||||||
OtherMiddleName: | BROOKE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2104 LEWIS TURNER BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT WALTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 325471316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508623728 | ||||||||
FaxNumber: | 8508626270 | ||||||||
Practice Location | |||||||||
Address1: | 2104 LEWIS TURNER BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT WALTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 325471316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508623728 | ||||||||
FaxNumber: | 8508626270 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2012 | ||||||||
LastUpdateDate: | 05/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT15331 | FL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 012179000 | 05 | FL |   | MEDICAID |