Provider Demographics
NPI:1659424380
Name:KIESOW, JAIME STOREY (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:STOREY
Last Name:KIESOW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:JAIME
Other - Middle Name:LYNN
Other - Last Name:STOREYSMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:85 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3707
Mailing Address - Country:US
Mailing Address - Phone:207-829-8007
Mailing Address - Fax:207-829-8008
Practice Address - Street 1:85 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:ME
Practice Address - Zip Code:04021-3707
Practice Address - Country:US
Practice Address - Phone:207-829-8007
Practice Address - Fax:207-829-8008
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1178225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME133260099Medicaid