Provider Demographics
NPI:1942667134
Name:ERVIN, RACHAEL MARIE (COTA/L)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:MARIE
Last Name:ERVIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:MARIE
Other - Last Name:MCCAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:3950 S GILDA CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67215-1768
Mailing Address - Country:US
Mailing Address - Phone:316-282-6144
Mailing Address - Fax:
Practice Address - Street 1:712 N MONROE AVE
Practice Address - Street 2:
Practice Address - City:SEDGWICK
Practice Address - State:KS
Practice Address - Zip Code:67135-9492
Practice Address - Country:US
Practice Address - Phone:316-772-5185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00716224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant