Provider Demographics
NPI:1073111340
Name:FREDERICK, KAYLA (OTR)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1398 N MILBURN SQ NE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:OH
Mailing Address - Zip Code:44612-8660
Mailing Address - Country:US
Mailing Address - Phone:330-324-2420
Mailing Address - Fax:
Practice Address - Street 1:2714 AKRON RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-7933
Practice Address - Country:US
Practice Address - Phone:330-262-4449
Practice Address - Fax:330-262-4449
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011231225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist