Provider Demographics
NPI:1780254110
Name:ANDERSON, KATHRYN ELISE CORNELL (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ELISE CORNELL
Last Name:ANDERSON
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 1:9807 N 2350 RD
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-4128
Mailing Address - Country:US
Mailing Address - Phone:580-330-2434
Mailing Address - Fax:
Practice Address - Street 1:602 W CHISHOLM DR
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-4348
Practice Address - Country:US
Practice Address - Phone:405-375-4194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2147224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant