Provider Demographics
NPI:1699178996
Name:HACKETT, KIM LEE (COTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LEE
Last Name:HACKETT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 FARNHAM ST
Mailing Address - Street 2:APT. 6
Mailing Address - City:MARSHALL
Mailing Address - State:WI
Mailing Address - Zip Code:53559
Mailing Address - Country:US
Mailing Address - Phone:608-320-9203
Mailing Address - Fax:
Practice Address - Street 1:425 FARNHAM ST
Practice Address - Street 2:APT. 6
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9624
Practice Address - Country:US
Practice Address - Phone:608-320-9203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5119-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant