Basic Information
Provider Information | |||||||||
NPI: | 1881160554 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PADGETT | ||||||||
FirstName: | CLARISA | ||||||||
MiddleName: | CAMILLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCQUEEN | ||||||||
OtherFirstName: | CLARISA | ||||||||
OtherMiddleName: | CAMILLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 108 MCINTOSH DR | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | KY | ||||||||
PostalCode: | 404759161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064938259 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2520 REGENCY RD STE 150 | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405033060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592240834 | ||||||||
FaxNumber: | 8592240882 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2018 | ||||||||
LastUpdateDate: | 11/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 245325 | KY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.