Provider Demographics
NPI:1083269625
Name:KIRBY, MIKAELA ELYSE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:ELYSE
Last Name:KIRBY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41940 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-8607
Mailing Address - Country:US
Mailing Address - Phone:623-255-9934
Mailing Address - Fax:
Practice Address - Street 1:42211 N 41ST DR STE 145
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3812
Practice Address - Country:US
Practice Address - Phone:602-808-9912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007871225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics