Provider Demographics
NPI:1265040737
Name:ADDISON, KIMBERLY (OTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ADDISON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9807 N FM 620 RD APT 14210
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-2272
Mailing Address - Country:US
Mailing Address - Phone:512-786-5983
Mailing Address - Fax:
Practice Address - Street 1:11110 TOM ADAMS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-3354
Practice Address - Country:US
Practice Address - Phone:512-836-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214929224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant