Provider Demographics
NPI:1518491653
Name:SEARLES, KIMBERLY ANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:SEARLES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:TYSSELING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1962
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-1962
Mailing Address - Country:US
Mailing Address - Phone:602-718-6750
Mailing Address - Fax:
Practice Address - Street 1:3401 LOCKWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5613
Practice Address - Country:US
Practice Address - Phone:602-718-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-15
Last Update Date:2017-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2913224Z00000X
CA3165224Z00000X
AZ6824224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant