Provider Demographics
NPI:1033545173
Name:MICK, BRIAN P (COTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:MICK
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12717 W 57TH TER
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216-1608
Mailing Address - Country:US
Mailing Address - Phone:316-519-8142
Mailing Address - Fax:
Practice Address - Street 1:4700 INDIAN CREEK PKWY
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66207-4068
Practice Address - Country:US
Practice Address - Phone:417-207-9868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03741224Z00000X
KS18-0097225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant