Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 2021050217 | MO |
N | 224Z00000X | Occupational Therapy Assistant | OTA002360 | GA |
NPI | 1013676360 |
---|---|
Provider Name | Andrea Kincade |
First Address | O Fallon, MO 63366-4582 |
Second Address | O Fallon, MO 63366-4582 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2021 |
Last Update Date | 04/01/2022 |