Provider Demographics
NPI:1770176505
Name:CLINTON, KIRSTON (OTR/L)
Entity type:Individual
Prefix:
First Name:KIRSTON
Middle Name:
Last Name:CLINTON
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 1:112 AIRPORT BUS PARK DR STE F
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-7453
Mailing Address - Country:US
Mailing Address - Phone:931-685-8730
Mailing Address - Fax:
Practice Address - Street 1:112 AIRPORT BUSINESS PARK DR STE F
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-7453
Practice Address - Country:US
Practice Address - Phone:931-685-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6796225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist