Provider Demographics
NPI:1396376307
Name:YECKE, KIMBERLY HOPE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:HOPE
Last Name:YECKE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9221 N MORETO CIR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8870
Mailing Address - Country:US
Mailing Address - Phone:843-475-6699
Mailing Address - Fax:
Practice Address - Street 1:672 MARINA DR STE 104
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29492-9084
Practice Address - Country:US
Practice Address - Phone:843-475-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5014224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant