Provider Demographics
NPI:1942639919
Name:DESOTO, KENDRA C (COTA/L)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:C
Last Name:DESOTO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1476
Mailing Address - Country:US
Mailing Address - Phone:614-575-9003
Mailing Address - Fax:614-575-9101
Practice Address - Street 1:5500 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1476
Practice Address - Country:US
Practice Address - Phone:614-575-9003
Practice Address - Fax:614-575-9101
Is Sole Proprietor?:No
Enumeration Date:2013-11-10
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04681224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant