Provider Demographics
NPI:1831325729
Name:KISNER MCGRAW, CAROL M (OT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:KISNER MCGRAW
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:KISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:105 MAPLE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTOVER
Mailing Address - State:WV
Mailing Address - Zip Code:26501-4081
Mailing Address - Country:US
Mailing Address - Phone:304-241-1219
Mailing Address - Fax:304-322-4485
Practice Address - Street 1:26 COMMERCE DRIVE
Practice Address - Street 2:
Practice Address - City:WESTOVER
Practice Address - State:WV
Practice Address - Zip Code:26501
Practice Address - Country:US
Practice Address - Phone:304-241-1219
Practice Address - Fax:304-322-4485
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC007261L225X00000X
WV886225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1802136000Medicaid
WV1802136000Medicaid