Provider Demographics
NPI:1891120929
Name:HIMES, KERRY LYNN (COTA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
Last Name:HIMES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3079 SHANNONDALE RD
Mailing Address - Street 2:
Mailing Address - City:MAYPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16240-3213
Mailing Address - Country:US
Mailing Address - Phone:814-856-3305
Mailing Address - Fax:
Practice Address - Street 1:133 LAURELBROOKE DR
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-2653
Practice Address - Country:US
Practice Address - Phone:814-849-0497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP005694224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant