Provider Demographics
NPI:1114644804
Name:TRIVETT, KASIE (MOT)
Entity Type:Individual
Prefix:
First Name:KASIE
Middle Name:
Last Name:TRIVETT
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2593 N ROCKY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-6038
Mailing Address - Country:US
Mailing Address - Phone:704-641-2146
Mailing Address - Fax:
Practice Address - Street 1:2593 N ROCKY RIVER RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6038
Practice Address - Country:US
Practice Address - Phone:704-641-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6680225X00000X
SC225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114644804Medicaid
SC1114644804Medicaid