Provider Demographics
NPI:1326309774
Name:MOTON, KISCHA
Entity Type:Individual
Prefix:
First Name:KISCHA
Middle Name:
Last Name:MOTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62204-1110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3019 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62204-1110
Practice Address - Country:US
Practice Address - Phone:618-581-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003075224Z00000X
MO2009012937224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL107216491Medicaid