Basic Information
| Provider Information | |||||||||
| NPI: | 1023454964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BISHOP | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | HARTMAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTRL | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARTMAN | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | KATHRYN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OTRL | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12276 SAN JOSE BLVD STE 508 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322238618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12276 SAN JOSE BLVD STE 508 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322238618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2013 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | OT005684 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | OT15779 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 014829900 | 05 | FL | MEDICAID |