Provider Demographics
NPI:1760923080
Name:EBERSOLE, KAITLYN (OTR)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:EBERSOLE
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 1:860 AIRPORT FWY
Mailing Address - Street 2:STE 210
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3249
Mailing Address - Country:US
Mailing Address - Phone:817-507-1500
Mailing Address - Fax:
Practice Address - Street 1:860 AIRPORT FWY
Practice Address - Street 2:STE 210
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3249
Practice Address - Country:US
Practice Address - Phone:817-507-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118171225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics