Provider Demographics
NPI:1346601424
Name:WEAVER, KAITLYN R (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:R
Last Name:WEAVER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:R
Other - Last Name:MOUSSEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:122 JILLIAN WAY
Mailing Address - Street 2:
Mailing Address - City:GLENBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04401-1243
Mailing Address - Country:US
Mailing Address - Phone:207-990-0162
Mailing Address - Fax:207-990-0163
Practice Address - Street 1:248 STATE STREET
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412
Practice Address - Country:US
Practice Address - Phone:207-989-2034
Practice Address - Fax:207-989-5971
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA2981224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant