Provider Demographics
NPI:1417292376
Name:THOMAS, KONISHA (COTA/L)
Entity Type:Individual
Prefix:
First Name:KONISHA
Middle Name:
Last Name:THOMAS
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 1:1060 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8505
Mailing Address - Country:US
Mailing Address - Phone:502-647-5530
Mailing Address - Fax:
Practice Address - Street 1:1060 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8505
Practice Address - Country:US
Practice Address - Phone:502-647-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA5022224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant