Provider Demographics
NPI:1518449438
Name:KINGSBURY, KATLYN MAXWELL (OT)
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:MAXWELL
Last Name:KINGSBURY
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 1:522 AMHERST ST STE 22
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1030
Mailing Address - Country:US
Mailing Address - Phone:603-880-0448
Mailing Address - Fax:
Practice Address - Street 1:340 GRANITE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-4000
Practice Address - Country:US
Practice Address - Phone:603-626-0760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024033225X00000X
MEOT3530225X00000X
NH2804225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH2804OtherALLIED HEALTH