Provider Demographics
NPI:1235784851
Name:RICHESIN, MARY KAITLYN (COTA/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAITLYN
Last Name:RICHESIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAITLYN
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1204 FRYE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3052
Mailing Address - Country:US
Mailing Address - Phone:423-745-0434
Mailing Address - Fax:
Practice Address - Street 1:1204 FRYE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3052
Practice Address - Country:US
Practice Address - Phone:423-745-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3283224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant