Provider Demographics
NPI:1699392068
Name:MOONEYHAM, KITA RENEE (COTA)
Entity Type:Individual
Prefix:
First Name:KITA
Middle Name:RENEE
Last Name:MOONEYHAM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KITA
Other - Middle Name:RENEE
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:8733 BLACKMAN FERRY RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-0235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8733 BLACKMAN FERRY RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-0235
Practice Address - Country:US
Practice Address - Phone:903-506-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213706224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant