Provider Demographics
NPI:1922651512
Name:SCUDDER, KACI TAYLOR
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:TAYLOR
Last Name:SCUDDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ELMWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37030-2024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 S WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-5956
Practice Address - Country:US
Practice Address - Phone:931-525-5516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3268224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant