Basic Information
| Provider Information | |||||||||
| NPI: | 1992463954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KAYSIE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MOT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLLINS | ||||||||
| OtherFirstName: | KAYSIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 411169 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022411169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888304125 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7591 TYLERS PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450696308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137556600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2021 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31007612A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT012019 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0406425 | 05 | OH | MEDICAID |