Provider Demographics
NPI:1083090393
Name:VANCLEAVE, KAITLYN ANN (OT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ANN
Last Name:VANCLEAVE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1660
Mailing Address - Country:US
Mailing Address - Phone:417-926-3177
Mailing Address - Fax:
Practice Address - Street 1:207 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1660
Practice Address - Country:US
Practice Address - Phone:417-926-3177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015025130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist