Provider Demographics
NPI:1073092425
Name:HARDIE, KACIE
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:
Last Name:HARDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:
Other - Last Name:MATHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1115 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-4418
Mailing Address - Country:US
Mailing Address - Phone:903-439-5612
Mailing Address - Fax:
Practice Address - Street 1:1501 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4707
Practice Address - Country:US
Practice Address - Phone:903-335-8727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214410224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant