Provider Demographics
NPI:1457866766
Name:SCANLON, KACEY (OT)
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:SCANLON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8811 WARREN H ABERNATHY HWY
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-1228
Mailing Address - Country:US
Mailing Address - Phone:864-574-7282
Mailing Address - Fax:864-574-7664
Practice Address - Street 1:8811 WARREN H ABERNATHY HWY
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-1228
Practice Address - Country:US
Practice Address - Phone:864-574-7282
Practice Address - Fax:864-574-7664
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4473225X00000X
NY019407225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4473OtherSC LICENSE