Provider Demographics
NPI:1922606656
Name:MINNICK, KRISTINE KATE (COTA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:KATE
Last Name:MINNICK
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 1:4720 COUNTY ROAD 25
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:OH
Mailing Address - Zip Code:43334-9770
Mailing Address - Country:US
Mailing Address - Phone:740-272-0629
Mailing Address - Fax:
Practice Address - Street 1:6690 LIBERATION WAY
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-2532
Practice Address - Country:US
Practice Address - Phone:614-289-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007804224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant