Provider Demographics
NPI:1174181564
Name:KISOR, HALEY ALEXANDRA (OTD)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:ALEXANDRA
Last Name:KISOR
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6490 WEST RD
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-8637
Mailing Address - Country:US
Mailing Address - Phone:513-324-6417
Mailing Address - Fax:
Practice Address - Street 1:5572 PRINCETON RD
Practice Address - Street 2:
Practice Address - City:LIBERTY TWP
Practice Address - State:OH
Practice Address - Zip Code:45011-9726
Practice Address - Country:US
Practice Address - Phone:513-874-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0442179Medicaid