Provider Demographics
NPI:1700930203
Name:AULT, KENNA JOAN (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:JOAN
Last Name:AULT
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:KENNA
Other - Middle Name:JOAN
Other - Last Name:KINKADE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:63095 E 293 RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-6013
Mailing Address - Country:US
Mailing Address - Phone:918-787-6564
Mailing Address - Fax:
Practice Address - Street 1:63095 E 293 RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-6013
Practice Address - Country:US
Practice Address - Phone:918-787-6564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00375225X00000X
KS17-0119225X00000X
OK857225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist