Provider Demographics
NPI:1194403568
Name:ORTIZ, KYLIE GRACE (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:GRACE
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:GRACE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84339-0103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:435-716-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13456977-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist