Provider Demographics
NPI:1255896205
Name:KLEGG, KEVIN DANIEL (COTA/L)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DANIEL
Last Name:KLEGG
Suffix:
Gender:M
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 1:5700 PLEASANT RIDGE RD
Mailing Address - Street 2:APT 321
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5321 BEVERLY PARK CIR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-9253
Practice Address - Country:US
Practice Address - Phone:865-687-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2674224Z00000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant