Provider Demographics
NPI:1841417813
Name:KITCHEN, MARY YVONNE (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:YVONNE
Last Name:KITCHEN
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 1:133 W WINSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-6843
Mailing Address - Country:US
Mailing Address - Phone:918-504-5385
Mailing Address - Fax:
Practice Address - Street 1:133 W WINSTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-6843
Practice Address - Country:US
Practice Address - Phone:918-504-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT519225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200210410AMedicaid