Provider Demographics
NPI:1376936575
Name:KISH, MARCANDREA (COTA/L)
Entity Type:Individual
Prefix:
First Name:MARCANDREA
Middle Name:
Last Name:KISH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:573-348-8000
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-348-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014003503224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant