Provider Demographics
NPI:1407165228
Name:OTIS, KYLIE KRISTEN
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:KRISTEN
Last Name:OTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 VALLEYCREST DR
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:PA
Mailing Address - Zip Code:15321-1181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 S WATER ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15203-2307
Practice Address - Country:US
Practice Address - Phone:412-432-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE008767225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant