Provider Demographics
NPI:1467663831
Name:EASTMAN, KYLIE SUE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:SUE
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CORINTH ROAD
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:VT
Mailing Address - Zip Code:05038-8969
Mailing Address - Country:US
Mailing Address - Phone:802-685-4413
Mailing Address - Fax:
Practice Address - Street 1:71 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05663-5644
Practice Address - Country:US
Practice Address - Phone:802-485-3162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT073-0000084224Z00000X
NH1926224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant