Provider Demographics
NPI:1851900237
Name:KILLGORE, CODY MITCHELL (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:MITCHELL
Last Name:KILLGORE
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4723
Mailing Address - Country:US
Mailing Address - Phone:775-786-3040
Mailing Address - Fax:775-786-1887
Practice Address - Street 1:555 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4723
Practice Address - Country:US
Practice Address - Phone:775-786-3040
Practice Address - Fax:775-786-6942
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2572225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14931948OtherCAQH
NV250009343Medicaid