Provider Demographics
NPI:1487951158
Name:BRISCOE, CHASTITY DAWN (COTA)
Entity type:Individual
Prefix:MRS
First Name:CHASTITY
Middle Name:DAWN
Last Name:BRISCOE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:KS
Mailing Address - Zip Code:67457-9161
Mailing Address - Country:US
Mailing Address - Phone:620-897-7796
Mailing Address - Fax:
Practice Address - Street 1:704 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:KS
Practice Address - Zip Code:67063-1530
Practice Address - Country:US
Practice Address - Phone:620-897-7796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00358224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant