Provider Demographics
NPI:1639932395
Name:KAHLE, INDIA BROOKE (COTA/L)
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:BROOKE
Last Name:KAHLE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 RYE COVE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-3518
Mailing Address - Country:US
Mailing Address - Phone:276-229-8693
Mailing Address - Fax:
Practice Address - Street 1:132 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171
Practice Address - Country:US
Practice Address - Phone:276-694-3163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15521224Z00000X
VA0131002804224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant