Provider Demographics
NPI:1669155354
Name:SHUMATE, KAYLYN JO (COTA/L)
Entity type:Individual
Prefix:
First Name:KAYLYN
Middle Name:JO
Last Name:SHUMATE
Suffix:
Gender:F
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 1:650 CR B
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:KS
Mailing Address - Zip Code:67865-6550
Mailing Address - Country:US
Mailing Address - Phone:620-255-0992
Mailing Address - Fax:
Practice Address - Street 1:2160 ZINNIA LN
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2042
Practice Address - Country:US
Practice Address - Phone:620-624-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01494224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant