Provider Demographics
NPI:1588962286
Name:DIETHRICH, KYLE SHANE (COTA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:SHANE
Last Name:DIETHRICH
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 WATERTREE RD.
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803
Mailing Address - Country:US
Mailing Address - Phone:812-870-2416
Mailing Address - Fax:
Practice Address - Street 1:400 COLLEGE AVE.
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802
Practice Address - Country:US
Practice Address - Phone:812-917-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99045856A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant