Provider Demographics
NPI:1356773287
Name:KAUGHMAN, MCKENZIE LEE (COTA)
Entity type:Individual
Prefix:MISS
First Name:MCKENZIE
Middle Name:LEE
Last Name:KAUGHMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3373 HWY OO
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640
Mailing Address - Country:US
Mailing Address - Phone:573-760-6029
Mailing Address - Fax:
Practice Address - Street 1:801 BRIM STREET
Practice Address - Street 2:
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601
Practice Address - Country:US
Practice Address - Phone:573-431-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013026753224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant