Provider Demographics
NPI:1215247846
Name:WALACAVAGE, KIMBERLY KAY (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:WALACAVAGE
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 1:2130 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17921-1015
Mailing Address - Country:US
Mailing Address - Phone:570-875-1124
Mailing Address - Fax:
Practice Address - Street 1:2130 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:PA
Practice Address - Zip Code:17921-1015
Practice Address - Country:US
Practice Address - Phone:570-875-1124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-17
Last Update Date:2010-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOCOO6213L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist