Provider Demographics
NPI:1659781359
Name:WHITE, KINETRIA JOVON (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KINETRIA
Middle Name:JOVON
Last Name:WHITE
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 1:1737 BENNINGTON CT
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3136
Mailing Address - Country:US
Mailing Address - Phone:317-603-6774
Mailing Address - Fax:
Practice Address - Street 1:2800 S DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6403
Practice Address - Country:US
Practice Address - Phone:765-864-0237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002563A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant