Provider Demographics
NPI:1689122236
Name:AYRES, KACEY (LAT, ATC, CES)
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:AYRES
Suffix:
Gender:F
Credentials:LAT, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10364 WATER CREST DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-7477
Mailing Address - Country:US
Mailing Address - Phone:317-225-0411
Mailing Address - Fax:
Practice Address - Street 1:330 E VERNON AVE APT 8
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6819
Practice Address - Country:US
Practice Address - Phone:317-225-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN36003452A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program