Provider Demographics
NPI:1194044644
Name:SMITH, KEVIN D (COTA/L)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
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 1:1710 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4302
Mailing Address - Country:US
Mailing Address - Phone:217-402-7052
Mailing Address - Fax:765-762-6885
Practice Address - Street 1:200 SHORT ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:IN
Practice Address - Zip Code:47993-1031
Practice Address - Country:US
Practice Address - Phone:765-762-6887
Practice Address - Fax:765-762-6885
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001563A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant