Provider Demographics
NPI:1598321663
Name:PRIDDY, KACY KEITHA (OTR)
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:KEITHA
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7390 FM 1943 RD E
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:TX
Mailing Address - Zip Code:77664-8892
Mailing Address - Country:US
Mailing Address - Phone:409-429-6875
Mailing Address - Fax:
Practice Address - Street 1:1846 I-10 S
Practice Address - Street 2:SUITE 102
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707
Practice Address - Country:US
Practice Address - Phone:409-292-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119383225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist