Provider Demographics
NPI:1336305838
Name:UPCHURCH, DUSTIN NICOLE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:DUSTIN
Middle Name:NICOLE
Last Name:UPCHURCH
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 1:271 PETE UPCHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-3810
Mailing Address - Country:US
Mailing Address - Phone:606-340-3109
Mailing Address - Fax:
Practice Address - Street 1:271 PETE UPCHURCH RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-3810
Practice Address - Country:US
Practice Address - Phone:606-340-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3777225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist