Provider Demographics
NPI:1699321026
Name:KIMBRELL, CORINNE (COTA/L)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4412A ASH ST SW
Mailing Address - Street 2:
Mailing Address - City:MCCHORD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:98439-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2929 5TH AVE NE STE A
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6782
Practice Address - Country:US
Practice Address - Phone:253-447-8216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60904449224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant