Provider Demographics
NPI:1740918929
Name:LILES, KARISSA (OTR)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:LILES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12695 KY 57
Mailing Address - Street 2:
Mailing Address - City:TOLLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:41189-8534
Mailing Address - Country:US
Mailing Address - Phone:606-407-1000
Mailing Address - Fax:
Practice Address - Street 1:497 TUCKER DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9111
Practice Address - Country:US
Practice Address - Phone:606-759-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY279491225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist