Provider Demographics
NPI:1568936730
Name:MULLINS, KACIE
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:
Last Name:MULLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 ALPINE TRL
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2994
Mailing Address - Country:US
Mailing Address - Phone:317-519-4618
Mailing Address - Fax:
Practice Address - Street 1:218 ALPINE TRL
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2994
Practice Address - Country:US
Practice Address - Phone:317-519-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist