Provider Demographics
NPI:1083985535
Name:KINCANNON, KATHRYN (COTA/L)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:KINCANNON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:RUEHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1427 HAMPTON PARK LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 JESS PARRISH CT
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2147
Practice Address - Country:US
Practice Address - Phone:321-269-1894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-14
Last Update Date:2012-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11230224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant