Provider Demographics
NPI:1659591485
Name:KIONGO, PETER (MHS,OTR)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KIONGO
Suffix:
Gender:M
Credentials:MHS,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1930
Mailing Address - Country:US
Mailing Address - Phone:270-727-1023
Mailing Address - Fax:270-247-6669
Practice Address - Street 1:101 N 7TH ST
Practice Address - Street 2:#16 ROOM 102
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1801
Practice Address - Country:US
Practice Address - Phone:270-727-1023
Practice Address - Fax:270-247-6669
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1718OtherFIRST STEPS PROGRAM
KY1718OtherFIRST STEPS PROGRAM