Provider Demographics
NPI:1477757763
Name:WAITS, TINA L (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:L
Last Name:WAITS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 YORKSHIRE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:859-422-4568
Mailing Address - Fax:859-757-4649
Practice Address - Street 1:101 WINDSOR PATH
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324
Practice Address - Country:US
Practice Address - Phone:859-422-4568
Practice Address - Fax:859-757-4649
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4758225X00000X
KY133079225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY133079OtherKY STATE LICENSE
KY7100201870Medicaid