Provider Demographics
NPI:1528666088
Name:KENNINGTON, DAVIE MICHELLE (OTA)
Entity type:Individual
Prefix:
First Name:DAVIE
Middle Name:MICHELLE
Last Name:KENNINGTON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 N PARKDALE LN APT 2304
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-0051
Mailing Address - Country:US
Mailing Address - Phone:903-647-1102
Mailing Address - Fax:
Practice Address - Street 1:1100 SARAH SWAMY LN
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090
Practice Address - Country:US
Practice Address - Phone:903-647-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
TX209882224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209882OtherSELF