Provider Demographics
NPI:1831267897
Name:MADDOX, KATHERYN KELLY (OTR L)
Entity type:Individual
Prefix:MRS
First Name:KATHERYN
Middle Name:KELLY
Last Name:MADDOX
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 1:2606 GRANT LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0652
Mailing Address - Country:US
Mailing Address - Phone:573-819-1633
Mailing Address - Fax:
Practice Address - Street 1:525 N KEENE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6967
Practice Address - Country:US
Practice Address - Phone:573-882-7350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005250225X00000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO474003928Medicaid