Provider Demographics
NPI:1205089919
Name:BASHAM, VICKI YVONNE (OTR/L)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:YVONNE
Last Name:BASHAM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 LAKEPOINT VIEW RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-4466
Mailing Address - Country:US
Mailing Address - Phone:606-307-8349
Mailing Address - Fax:
Practice Address - Street 1:514 LAKEPOINT VIEW RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-4466
Practice Address - Country:US
Practice Address - Phone:606-307-8349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2012-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4058225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist