Provider Demographics
NPI:1740661966
Name:SHUEY, KAITLYN MASSEY (COTA/L)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MASSEY
Last Name:SHUEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:HALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:3171 S BOWN WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5665
Mailing Address - Country:US
Mailing Address - Phone:208-433-9152
Mailing Address - Fax:
Practice Address - Street 1:3171 S BOWN WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5665
Practice Address - Country:US
Practice Address - Phone:208-433-9152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1063224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant